.

Republic of the Philippines )

Quezon City ) S.S.
x------------------------------------x

AFFIDAVIT OF ACCIDENT

I, _______________________, Filipino citizen of legal age, single, and with postal

address at _______________________________________, after being duly sworn to in
accordance with law, hereby depose and state:

1. That I am a duly licensed driver with Non-Professional Driver’s License No.

_________________________ which is valid until _________________;

2. That I am the registered owner of a vehicle with the following details:

Make:
Series:
Body Type:
Year Model:
Plate No.:
Engine No.:

3. That on ______________ at around _______, I was driving along

_____________________ when a pedestrian suddenly crossed in front of my vehicle. I
swerved to the right in order to avoid hitting the pedestrian, and in the process I
accidentally hit a rock and a concrete street post.

4. That as a result of the accident, the right side of the front bumper and the right side
mirror of my vehicle were damaged, and the right rear passenger door had scratches
and dents;

5. That on __________ at around ___________, I went home after doing some errands.
Upon reaching our house, I was in the process of parking the abovementioned vehicle in
our garage when I accidentally hit the left rear side of the vehicle into our garage wall;

6. That as a result of the accident, the left rear tail light of my vehicle was broken;

7. That I am executing this Affidavit to attest to the truth of the foregoing and in support of
my claim against the insurer for the repair of the damages caused to my vehicle and for
other legal purposes.

IN WITNESS WHEREOF, I hereunto affix my signature this _______th day of

____________, _______in Quezon City.

________________________
Affiant

SUBSCRIBED AND SWORN TO before me this ____th day of _____________________

in Quezon City, affiant exhibiting to me his driver’s license with license no. No.
________________ expiring on _______________.

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of _______.