REPUBLIC OF THE PHILIPPINES )

IN THE CITY OF GENERAL SANTOS ) S.S.

AFFIDAVIT OF ACCIDENT REPORT

I, DEXTER CHRISTIAN G. BASAN, of legal age, single, Filipino, with

office/residence and postal address at Barangay Poblacion Tupi, South
Cotabato, Philippines, after having been subscribed to an oath, depose and say:

1. That I am the owner/manager/duly authorized representative of business

establishment named DCGB CHICKEN FOOD HOUSE located at KCC
Mall, General Santos City;

2. That on October 16, 2019 at around 7:00 o’clock in the evening, an

incident happened when an earthquake occurred causing damage to my
business wherein the front glass was broke and accidentally fall one of my
equipment;

3. That because of the said incident, there is a need to replace/changed the

glass and or repair the same as required on my said business;

4. That I execute this Affidavit to attest to the truth of the foregoing facts and
in support of the claim against the insurer for the repair of the damage
caused to my said business and for all legal purposes it may serve.

IN WITNESS HEREOF, I hereby set my hand this _____ th day of

_________________, 2019, in _______________________________.

DEXTER CHRISTIAN G. BASAN

Affiant

SIGNED, SUBSCRIBED AND SWORN to before me this __th day of

__________________________. Affiant exhibited to me his competent means
of identification as indicated above below his name.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2019