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 vehicle which is particularly described as follows:

MAKE AND MODEL :

SERIAL NUMBER :
MOTOR NUMBER :
PLATE NUMBER :

This affidavit is to confirm that I was involved in a self auto accident. Location of the incident was
in Naic, Cavite at approximately 2:00 pm on Wednesday, April 10, 2018. I was traveling southbound when
an individual riding a bike appeared from the right side of the street. In order to prevent hitting the
individual, the vehicle was maneuvered to the left side where it hit a side railing causing dents and
scratches to the left/driver side of the vehicle. This is an unfortunate self accident but still grateful that the
individual riding the bike was not harmed.

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