Maryknoll B.

Grospe
24-A Road 13 Bagong Pag-asa
Quezon City
grospemaryknoll@gmail.com
+639069039693

July 3, 2023

People’s General Insurance Corporation

420 Calle Magallanes Intramuros Manila

Re: Car Insurance Claim - Affidavit of Own Damage

Policyholder Name: Maryknoll Burgos Grospe

Policy Number: TBN-PC-TIP-00004485
Date of Incident: June 29, 2023

Vehicle Make: Toyota

Model: Vios 1.3 XLE CVT
Year: 2022

INCIDENT DETAILS

Under penalty of perjury, I, Maryknoll B. Grospe, hereby make the following

solemn affirmation:
1. On June 29, 2023, at approximately 9:00 in the morning, I discovered
damage to my car while it was parked in front of my apartment located at
24-A Road 13 Bagong Pag-asa, Quezon City. I noticed a crack on the left
rear bumper and damage to the compartment cover of my Vios 1.3 XLE
CVT, which is registered under the insurance policy mentioned above.
2. As soon as I observed the damage, I promptly reported it to the nearest
Toyota branch to obtain a quotation for repairs. During the visit, they made
a photocopy of the insurance policy, took a photograph of the reported
damage, and requested a copy of my driver's license ID.
3. There were no witnesses present at the time of the incident, and
unfortunately, no CCTV cameras were installed in the vicinity that could
have captured what caused the damage.
4. Regrettably, the dashcam in my vehicle did not record the incident.

I declare that the statements provided in this affidavit are true and accurate
to the best of my knowledge and belief.

Maryknoll B. Grospe

SUBSCRIBED AND SWORN to before me this ____ day of

___________, 2023 at ___________________________, affiant exhibiting
to me his ________________________ with
___________________________ as competent evidence of his identity.

Doc No. ____

Page No. ____
Book No. ____
Series of 2023.