REPUBLIC OF THE PHILIPPINES )

Municipality / City of _________________) S.S.

AFFIDAVIT OF ACCIDENT

I, JOSEPH O. AROY, Filipino, of legal age, single, with address at 87 Talisay St. Libis
Bulelak, Malanday, Marikina City, Philippines, after having been sworn in accordance with
law, hereby depose and state that:

1. I am the driver of the motor cycle with Plate No. 180103 owned by Hauz of Pancit
Malabon under the registered owner name Doloras Warehouse Office Inc.

2. At around 3:00PM of January 5, 2024, while I was driving the aforesaid vehicle along
Commonwealth Avenue Quezon City, the front wheel was suddenly locked due to defect of
the other parts which caused me to fall along the road. Due to this incident the front of the
vehicle including its headlight and the shock were damaged.

3. That I’am executing this affidavit for the purpose of claiming an insurance in behalf the
registered owner.

4. I am executing this affidavit for purposes of attesting to the truth of the foregoing, and
for whatever legal purpose it may serve.

JOSEPH O. AROY
Affiant

SUBSCRIBED AND SWORN to before me this _____________ at _________________

affiant presenting to me his competent evidence of identity by way of the following:

Doc. No.:
Page No.:_________
Book No.: ________
Series of 2024