REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI )S.S

AFFIDAVIT OF CAR INCIDENT

I, CATHERINE CASIM DULOT, of legal age, Filipino, single and with
residence address at 1802 Dian St. Brgy Palanan, Makati City, After having been duly
sworn to in accordance with law, do hereby depose and state:

That I am the registered owner of a motor vehicle more particularly described as

follows:
MAKE/TYPE : Chevrolet/AUV PLATE NO. : AKA 3443
YEAR MODEL : 2015 CR NO. : 219127952
ENGINE NO. : F7X0564* OR NO. : 1844990733
CHASSIS NO. : MJBJA75B0F0103612

That on June 14, 2020, I parked the aforementioned vehicle overnight near my
house where I usually park my car. When I was about to get to the said vehicle in the
morning and found that their are bite marks of dogs that caused gnawed and scratches on
the front left fender. It also sustained damage on the front left and right bumber and
under the front left door of the driver side. The said incident caused heavy scratches from
all sides of the car;

That the aforementioned situation was an incident beyond my control after

exercising extraordinary care and diligence to safety;

That I am executing this affidavit to attest to the truth of the foregoing facts and
for the purpose of an Insurance Claim in hands of People’s General Insurance
Corporation at 420 Calle Magallanes, Intramuros, Manila.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 19 th day of

June 2020 at the City of Makati.

CATHERINE CASIM DULOT

Affiant

Subscribed and sworn to before me this 19 th day of June 2020 at the City of
Makati, and affiant exhibiting to me her Driver’s License ID No. N26-03-001954.

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