Republic of the Philippines )

City of Santa Rosa )

Laguna )s.s.

AFFIDAVIT OF INCIDENT

I, xxxxx, of legal age, Filipino, married, and residence of Lot 1544 Block
220, Fortuna, San Pedro, Laguna, after being sworn in accordance with the law,
hereby depose and state that:

1. I am a Unit Manager of Caadfadfasdo Life (Philippines), Inc.;

2. I am the lawful owner of a motor vehicle, more particularly describe as

follows:

Make :
Type :
Model :
Engine Number :
Conduction Sticker Number:
MV File No.:
Plate Number: not yet issued

3. On 28 November 2014 (Monday), at around 3:25 in the afternoon after

having a meeting with my client about insurance policy at Sun Life
Center, while approaching C-5 Road going back to our home at Sta.
Rosa, Laguna, approximately 300 meters before the C-5 toll gate entry
point, I was shocked when a hard object, seems stone, stroked in my
wind shield;

4. I immediately hazard my motor vehicle, and stopped right after the C-5
toll gate to check on my wind shield;

5. Upon checking, I noticed there was cracked in my wind shield brought

about by said hard object;

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

statements and for any legal purpose it may serve.

AFFIANT

Subscribed and sworn to before me this 23rd day of November 2018 at City
of Sta. Rosa, Laguna, Affiant exhibited to me her Driver’s License Number
____________, issued on ______________at
______________________________, with expiration period of
_________________.

Doc. No. : ________

Page No.: ________
Book No.: ________
Series of ________