REPUBLIC OF THE PHILIPPINES)

CITY OF )

AFFIDAVIT OF ACCIDENT

I, , Filipino, of legal age, with residence

address at , after having been duly
sworn to in accordance with law, hereby, depose and say that:

I am the authorized driver of one motor vehicle which is particularly described

as follows:

MAKE AND MODEL :

SERIAL NUMBER :
MOTOR NUMBER :
PLATE NUMBER :

On January 24, 2013 at around four o’clock in the afternoon, I was driving along
Airport Road at Parañaque City going southbound. In the same lane, a ten-wheeler truck
was also traversing the road on my right side on a fast speed. As the truck was very fast, I
did not immediately notice that it sideswiped the right side portion of my driven vehicle.
Unfortunately, I was not able to stop the driver of the truck nor get the plate number of
the truck. The accident happened so fast and went beyond my control.

I am executing this affidavit to attest to the truth of the foregoing statement and
in support of my claims for reimbursement from the insurance company.

Affiant

SUBSCRIBED AND SWORN to before me this day of ,

20 at , Affiant exhibiting to me his/her Residence Certificate
No./ Valid Identification issued at

on .

NOTARY PUBLIC

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