Republic of the Philippines)

Antipolo City ) S.S.

AFFIDAVIT OF ACCIDENT

I, LIZA V. JOSON, of legal age, and a resident of No. 45 Nido

St., Oro Vista Royale Executive Village, Barangay Mayamot, Antipolo City,
Rizal, after having been sworn to in accordance with law hereby depose and
say:

1. That I am the driver/ owner of a motor vehicle, with plate No.

POB 926 and insured with Prudential Guarantee and Assurance Inc., with
policy No. MC-CMV-CBC-0000124 and more particularly described to
wit:

MAKE: MAZDA
MOTOR NO. L510529502
SERIAL NO. JM7ER19L9B0224066

2. That on October 18, 2013, at around 7:30 in the morning while

driving the said car along our Village, when to my surprised a car with
plate no. UYQ 862, coming out from right side or another street to my way,
without my noticed, causing to hit and bumped the aforesaid car , and
causing the damages of my car and the said car, as shown in the pictures
with an estimated amount of P__________, more or less.

3. That I am executing this affidavit to attest to the truth of the

foregoing and in connection with the claims in the said insurance.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___ day of October 2013 in Antipolo City.

LIZA V. JOSON
Affiant
Driver license No. D16- 00-224521

SUBSCRIBED AND SWORN, to in before me this ___ day of

October 2013 in Antipolo City, with her driver license present to me to
prove his identity.