Republic of the Philippines)

_____________________)s.s.

AFFIDAVIT OF VEHICULAR ACCIDENT

I, JOSEPH PACAPAC, of legal age, Filipino Citizen, married and with postal address at and with
postal address at Block 8 Lot 2 Magnolia St., West Fairview, Quezon City, after having been duly sworn
to in accordance with law, do hereby depose and state:

1. That I am a duly licensed driver with Driver’s License No. A08-92-004782 which is valid
until 19 December 2023. Attached herewith as Annex “A” is the copy of my driver’s license;

2. That I am the authorized driver of one motor vehicle owned by MONOCRETE

CONSTRUCTION PHILIPPINES, INC., which is more particularly described as follows:

MAKE : Toyota
SERIES : Fortuner 4x2 2
BODY TYPE : SUV
YEAR MODEL : 2016
PLATE NO. : NCY4516

Attached herewith as Annexes “B” and “C” copies of the Official Receipt and Certificate of
Registration.

3. That on 03 December 2019 at around 2:20 in the afternoon, during a stormy afternoon, I was
driving along EDSA flyover, Santolan Road. In front of me is a Toyota hi-ace commuter van bearing
plate number CAN 1860 being driven by Mr. Sonny P. Dugenia. While the traversing the said lane, the
said Toyota Hi-Ace Commuter Van suddenly stopped and as such I hit the back portion of the Toyota Hi-
Ace van which caused dents and scratches on the same. Attached herewith as Annexes “D”, “E” and “F”
are the copies of the driver’s license of Mr. Sonny P. Dugenia and the Certificate of Registration and
Official Receipts of the said vehicle, respectively. Attached likewise as Annex “G” is the picture of the
above-mentioned vehicle.

4. That since it was a stormy afternoon and to prevent delays and cause heavy traffic, we have
decided not to secure a Police Report for the said incident and instead settle the same amicably

5. That I am executing this affidavit to attest to the truth of the foregoing narrated facts and in
support of the claim against the insurer.

IN WITNESS WHEREOF, I have hereunto signed this ___th day of _________, at _________,
Philippines.

______________________
JOSEPH PACAPAC
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this ____ day of ___________ at

_______________, affiant exhibiting to me his Driver’s License No. A08-92-004782 which is valid until
19 December 2023 bearing his picture and signature thereon as a competent proof of his identity.

Doc. No. ______;

Page No. ______: NOTARY PUBLIC
Book No. ______;
Series of _______.

Affidavit of Vehicular Accident

LF0399-2018