Republic of the Philippines )

_____________ ) S.S.

AFFIDAVIT OF INCIDENT

I, __________________, Filipino, of legal age, married, and a resident of

___________________________, after having been duly sworn to in accordance with law
hereby depose and state that:

1. I am the driver of a motor vehicle registered to ______________________ more

particularly described herein as follows, to wit:

2. Last __________ at about _____________ I was driving ____________________

when a motorcycle going the same direction wrongfully bumped the rear portion
of the above-mentioned car causing the rear bumper to be detached from the
body and the same rear part incurred some scratches;

3. I have exercised all due diligence beforehand of said incident to avoid the
occurrence of the same, however, it would seem that said incident was
inevitable;

4. I am executing the foregoing affidavit in compliance with the requirements for

insurance claims for the above-described vehicle; and

5. I have executed this affidavit to attest to the truth and veracity of the foregoing
statements, and for whatever other legal purposes the same may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

__________________________ Philippines.

____________________
Affiant
Driver’s License No. ___________________

SUBSCRIBED AND SWORN TO Before me a Notary Public for and in the

________________, Philippines, this ________________. Witness my hand and seal.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2022.