REPUBLIC OF THE PHILIPPINES)

MAKATI CITY ) S.S.

AFFIDAVIT OF VEHICULAR ACCIDENT

I, _______________________, of legal age, Filipino, married and with office address at

7F Universal Re Building 106 Paseo de Roxas, Makati City, under oath, state:

1. That Benguet Corporation (“BC”) is the registered owner of a motor vehicle which is
specifically described as follows:
TOYOTA VIOS
Model : 2013
Motor No. : 2NZ68236487326
Chassis No. : NCP2364893274
Color : Silver
Plate No. : UZI-678

2. That I am a company driver of BC, and that the above-mentioned motor vehicle was
assigned to me as a door-to-door service vehicle of ABC employees;

3. That the said motor vehicle figured an accident on 15 September 2021 at about 6:00PM
while I was driving it along West Service Road, Paraňaque, Metro Manila, and as I was
trying to turn left going to SMDC Spring Residences, a motorcycle tried to overtake me
in the inner portion thus grazing and scraping the left passenger door which thus
sustained considerable damage to the said motor vehicle;

4. That I and the driver of the motorcycle did not bother anymore to summon a policeman to
record the accident as we were both in a hurry and that there were still employees in the
office waiting to be brought home; and

5. That I am executing this affidavit to attest to the truth of the foregoing circumstances and
for the purpose of reporting the matter to my insurance office for insurance claims.

IN WITNESS WHEREOF, we have signed by these present on _______________ at

Makati City.

_________________
 SUBSCRIBED AND SWORN to before me this ________________in Makati City, the
affiant exhibited to me her Driver’s License with ID No. H02-02-12345.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2021.