REPUBLIC OF THE PHILIPPINES )

CITY OF ___________________________
) S.S.

AFFIDAVIT OF NO COMPREHENSIVE CAR INSURANCE

I, Lebron James, of legal age, Filipino, married, and a resident of 123 Malacanang
Palace, after having been duly sworn to in accordance with law, depose and state
that:

1. I am a duly licensed driver with LTO Driver’s License with No. D10-12-
2345678 under O.R. Number 123456789;

2. That on May 25, 2021 at around 5:00pm, I was driving a motor vehicle
owned and registered in my name which is more particularly described as
follows:

Make: Honda Model: Civic

Chassis: ABCD123456789 Engine: A123456789
Plate Number: ABC 1234 Year Model: 2017

3. That, while I was fully stopped at the employee parking area of Corporate
Office Bldg Quezon City, another vehicle was backing up and accidentally
hit my vehicle’s front right side.

4. The vehicle who caused damage to my vehicle is driven by Michael Jordan

and is more particularly described as follows:

Make: Toyota Model: Fortuner

Chassis: Engine:
Plate Number: DEF 5678 Year Model:

5. As a result of the incident, my vehicle sustained damages particularly on its

front right fender and front bumper

6. That as of the present time, the vehicle above described, which I own, is not
under any comprehensive vehicle insurance by any insurance company;

7. That I am executing this Affidavit to attest to the truth of the foregoing and
for any other purpose this affidavit may serve.

8. Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this day of

2021 in City of ________________, Philippines.

LEBRON JAMES
Affiant
 SUBSCRIBED AND SWORN to before me this day of 2021
in ____________________, affiant exhibiting to me a copy of his Driver’s license with No.
D10-12-2345678.
Notary Public

Doc No.
Page No.
Book No.
Series of 2021