F-CL-01

Revision No.: 04
Revision Date: February 17, 2020

Motor Vehicle Accident Report Form Claim No.

Important Notice: This form is to be accomplished by the Assured and the one driving the unit at the time of
accident. It is required that all information, as applicable, is indicated in the space provided for. Your insurer,
BPI/MS Insurance Corporation, must be immediately notified after the accident with this form fully
accomplished and submitted. (Please refer to your Motor Claims Guide for other information)
Date Accomplished 09/19/2022
Name of Insured Jovit P Porras Policy No. DP807574
Residence Address 5450-B Lawin St. CAB,Mabalacat City, Home Phone No.
Pampanga
Mailing Address Office Phone No.
Email Address: Jovitporras5421@gmail.com Mobile No. 09466058911

INSURED VEHICLE ADVERSE VEHICLE

Registered Owner of Vehicle Jovit P Porras
Make & Model 2020 Toyota Avanza Blue
1.3
Plate No. CAU-9907

Name of Driver Jovit P Porras

Address 5450-B Lawin St.
CAB,Mabalacat City,
Pampanga
Tel No. 09466058911
Relation to owner of vehicle N/A

License No. C10-14-002007

Issued: ANGELES CITY Date/Place: 12/30/2021 Date/Place:

Insurer of Vehicle BPI/MS

Policy No. DP807574

Brief description of point/s of impact Brief description of point/s of impact

FRONT BUMBER LEFT SIDE

DETAILS OF THE ACCIDENT Date: 08/02/2022 Time: 5:30PM

th
Place: CJVAB, Pasay City, 250 Presidential Airlift Wing
Facts:

I was maneuvering to park my car in front of my office but suddenly I miscalculated the corner of
the parking area and bumped into a steel rod from the corner of the left side of my car.

Sketch of the Accident:

(Please sketch the full details: street name, curbs, corners, position of the vehicles involved after impact and mark point/s of impact

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 F-Cl-01
Revision No. 04
Revision Date: February 17, 2020

 Please sign here

Signature of Driver-Insured Vehicle Signature of Driver-Adverse Vehicle

Property/ies involved other than the

insured vehicles
Owner of the Property
Address
Brief description of damage/s
sustained:

If in case there shall be person/s or victim/s injured in an accident, please secure the following information
and details:
Name Address Age Remarks

Pursuant to IC Circular Letter No. 50-2016, Section 5: Fraud Warning

“Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or
imprisonment of two (2) years, or both, at the discretion of the court, to any person who presents or causes to be
presented any fraudulent claim for the payment of a loss under a contract of insurance, and who fraudulently
prepares, makes or subscribes any writing with intent to present or use the same, or to allow it to be presented in
support of any claim.”

Data Privacy. Pursuant to the foregoing Claim, I consent to the collection, use, processing and transfer of my
personal data as described in this paragraph. I understand that the Company and/or its related companies hold
certain personal information about me (including my name, address and telephone number, date of birth, social
security number, tax identification number, etc.) for the purpose of processing my/ the Claim. I also understand
that the Company may transfer this Data amongst its related companies as necessary for the purpose of
processing, administering and managing my/ the Claim, and that the Company may also transfer this Data to any
third parties assisting the Company in the processing, administration and management of the Claim. I authorize
them to receive, possess, use, retain and transfer the Data, in electronic or other form, for these purposes. I also
understand that I may, at any time, review the Data, require any necessary changes to the Data or withdraw my
consent in writing by contacting the Company. I further understand that withdrawing my consent may
substantially affect my ability to further process and collect on my/ the Claim.

I/We hereby declared that the above statements and facts are true and correct, to the best of my
knowledge and belief and that I/We have not withheld from the company any information within
my/our knowledge connected with the above-mentioned accident.

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 Please sign here________
Assured’s Signature/Date
F-Cl-01
Revision No. 04
Revision Date: February 17, 2020
__________________________________
Signature of Adverse Party’s Driver/Date

 Please sign here________

Driver’s Signature/Date

Signed in the presence of:

__________________________ ______________________________

SUBSCRIBE AND SWORN TO BEFORE ME THIS ________________ DAY OF _________ ________

IN ________________________ AFFIANTS EXHIBITING TO ME THEIR RESIDENCE CERTIFICATE NOS.
___________________________________ ISSUED AT _______________________ ON ____________
AND ___________________ ISSUED AT _______________________________ ON ________________

Doc. No. ______________ NOTARY PUBLIC

Page No. ______________ Until December 31 ___________
Book No. ______________ PTR No. ___________ Issued on _____________
Series of ______________ At _____________________________________

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