REPUBLIC OF THE PHILIPPINES)

City of )S.S

A F F I D A V I T OF D A M A G E

I, __________________________________, of legal age, Filipino citizen

and a resident of No.______________________________________________,
after being duly sworn to in accordance with law, hereby depose and state:

That, on __________________ at about ______________________, I

was driving a motor vehicle described as follows:

Year/Make/Type : ___________________________
Motor No. : ___________________________
Serial No. : ___________________________
Plate No. : ___________________________
Owned by : ___________________________
Policy No. : ___________________________

That while I was driving the aforesaid vehicle along

_______________________ a vehicular accident occurred in the following
manners:

 ___________________________________________________________
_

That I have executed this affidavit to attest the truth of the aforementioned
acts under oath for insurance purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this __________

day of __________ in the City of ______________________.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _________, 2018,

affiant exhibiting to me his/her residence certificate no. ________________
issued on ____________ at ____________.

NOTARY PUBLIC

Doc. No. ______

Page No. ______
Book No. ______
Series of 2018