REPUBLIC OF THE PHILIPPINES)

______________ ) S.S.

AFFIDAVIT OF ACCIDENT

I, _________________, of legal age, Filipino, with residence address at ___________________,

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

1. I am the owner of motor vehicle with Driver’s License No. ______________ issued by
the Land Transportation Office (LTO).

2. On _______________ in the ___________, I was driving the said motor vehicle, which
is more particularly described as follows:

Make :
Body Type :
Chassis No. :
Plate No. :
CR No. :
Engine no. :
Year model :
MV file no. :

3. While I was driving along the ___________________. I was maneuvering the said
vehicle then I accidentally hit the gutter in the said parking area which damaged the step
board of the vehicle.

4. I am executing this Affidavit to attest to the truth of the foregoing and in support of my
claim for insurance.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this __________ at ________.

_______________________
Affiant
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
_______________________________
Affiant
SUBSCRIBED AND SWORN to before me in Pasig City this 24
th
day of
July, 2013 by ____________________, who has satisfactorily proven to me her
identity through __________ with number ______________ issued at ___________
valid until ______________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
_______________________________
 Affiant
SUBSCRIBED AND SWORN to before me in Pasig City this 24
th
day of
July, 2013 by ____________________, who has satisfactorily proven to me her
identity through __________ with number ______________ issued at ___________
valid until ______________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
_______________________________
Affiant
SUBSCRIBED AND SWORN to before me in Pasig City this 24
th
day of
July, 2013 by ____________________, who has satisfactorily proven to me her
identity through __________ with number ______________ issued at ___________
valid until ______________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
_______________________________
Affiant
SUBSCRIBED AND SWORN to before me in Pasig City this 24
th
day of
July, 2013 by ____________________, who has satisfactorily proven to me her
identity through __________ with number ______________ issued at ___________
valid until ______________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
_______________________________
Affiant
SUBSCRIBED AND SWORN to before me in Pasig City this 24
th
day of
July, 2013 by ____________________, who has satisfactorily proven to me her
identity through __________ with number ______________ issued at ___________
valid until ______________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
 day of July, 2013
_______________________________
Affiant
SUBSCRIBED AND SWORN to before me in Pasig City this 24
th
day of
July, 2013 by ____________________, who has satisfactorily proven to me her
identity through __________ with number ______________ issued at ___________
valid until ______________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
_______________________________
Affiant
SUBSCRIBED AND SWORN to before me in Pasig City this 24
th
day of
July, 2013 by ____________________, who has satisfactorily proven to me her
identity through __________ with number ______________ issued at ___________
valid until ______________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013
IN WITNESS WHEREOF, I have hereunto affixed my signature this
24
th
day of July, 2013

SUBSCRIBED AND SWORN to before me in ________ this _______________, affiant

exhibiting to me her _______________.

Doc . No.
Page No.
Book No.
Series of