REPUBLIC OF THE PHILIPPINES)

PROVINCE OF METRO MANILA)

CITY OF LAS PIÑAS )S.S.
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AFFIDAVIT OF SELF-ACCIDENT

I, NEILMER DAGANIO DAIZ, of legal age, single, Filipino, a resident of B24 L21 Elysian
Subd., Imus City, Cavite, after being sworn in accordance with law, do hereby depose and say:

1. That I am a holder of Non-Professional Driver License No. N26-15-024423 issued by

the Land Transportation Office with validity until 04/07/2023;

2. That I am the owner of a motor vehicle particularly described as follows:

Make/Type : Yamaha/MIO BB36

Year Model : 2019
Engine No. : E3R2E-2601952
MV File No. : 0401-00001180253

3. That sometime on July 1, 2021 around 6 o’ clock in the evening, I was driving back
home with the above-mentioned motor vehicle. The weather during that time was
raining nonstop and roads were wet and slippery. Subsequently, I accidentally
overturned the swing arm handle bars of my motor vehicle which caused the lower
front right fender and right portion of the motor vehicle to graze upon the concrete
pavement of the road and resulted to paint scratches and paint scrape on the
portion of the said vehicle.

4. Upon fixing the motor vehicle position, I am alighted and took pictures on the
damaged portion of the vehicle, which pictures are attached to this affidavit;

5. I am executing this affidavit to attest the truthfulness of foregoing statement and in

support in my claims for the repair and insured vehicle from Pioneer Insurance, the
insurance company.

NEILMER DAGANIO DAIZ

Affiant
SUBSCRIBED AND SWORN to before me this 10th of August 2021 in the City of Las Piñas.