REPUBLIC OF THE PHILIPPINES)

CITY OF MANDAUE.................)

AFFIDAVIT OF ACCIDENT

I, JUNLEY S. CABALLERO, Filipino, of legal age, and a resident of Talaga, Argao, Cebu,
Philippines after having been duly sworn to in accordance with law, hereby, depose and say
that:

I am the authorized driver of a motorcycle which is particularly described as follows:

Make: SUZUKI Series: FW110D

Chassis No.: BE4DX433770 MV File No.: 0701-00000136388
Engine No.: E472350683 Plate No.: GC 77106

On September 28, 2017 at around 4:15 in the afternoon, I was on my way to deliver the
passbook of a client who was in One Oasis Cebu. As I was traversing along Hernan Cortes St.,
Mandaue City going to F. Cabahug St., Mandaue City, I met a minor accident. The driver of a
multicab, which was parked near the intersection, suddenly opened its door as I was
executing a left turn going to F. Cabahug St., Mandaue City. In order to avoid the imminent
collision, I made a full stop which caused me to fall from the motorcycle. As I saw no fatal
injuries on my person, I decided to go on my way and not bother to formally report it to the
proper authorities. However, as I felt an uncomfortable sensation in my left hand, I decided
to have it x-rayed on October 3, 2017. The x-ray revealed that the incident caused a crack on
my left hand thus a cast was placed on it to facilitate the healing of the broken bones.

I am executing this affidavit to attest to the truth of the foregoing statement and in
support of claims for reimbursement of the expenses that I incurred and to claim the benefits
I am entitled to for reason of the accident that I suffered during the performance of my work.

JUNLEY S. CABALLERO
Affiant
_____________________

SUBSCRIBED AND SWORN to before me, this at Mandaue City,

with affiant showing his government issued ID appearing on the line below his name.

WITNESS MY HAND AND SEAL.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2017.