REPUBLIC OF THE PHILIPPINES)

PROVINCE OF PAMPANGA )S.S.

CITY OF ANGELES )
x----------------------------------------x

AFFIDAVIT OF ACCIDENT

I, PARK WON-LARK, of legal age, Korean national, and with address at Blk. 3,
Lot 1, Bongavilla St., Timog Hills, Pampang, Angeles City, Pampanga, after having
been duly sworn to in accordance with law, depose and state that:

1. I am the owner, authorized driver, and a holder of a comprehensive insurance

policy with CGIC for a vehicle described as follows;

MAKE AND MODEL: 2024 FORD NEXT-GEN TERRITORY

PLATE NO. CCB3726
COLOR: BLUE METALLIC
ENGINE NO. P5G053311
CHASSIS NO. LJXCU2BB2RTF16548

2. On the night of January 14, 2024, around 11:00p.m., while my car was
properly parked along Yukon St., Anunas, Angeles City, some yet unknown
persons attacked and hit both of the side mirrors and some parts of the body
of my aforementioned vehicle. As a result, both of the said side mirrors
sustained damages and were almost, if not, were already broken off and
caused dents on some parts of its body;

3. Said incident happened beyond my will and control and I do not have the
slightest intention of causing or inflicting such damage on my own vehicle as I
have been observing proper diligence in caring for the same;

4. I am executing this affidavit to attest to the truth of the foregoing in support

of my claims from the comprehensive insurance policy for the reimbursement
and/or cost of repairs and for whatever legal intents and purposes this may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of

January, 2024 at the City of Angeles, Pampanga, Philippines.

PARK WON-LARK
Affiant

SUBSCRIBED AND SWORN to before me this 19th day of January, 2024 at the
City of Angeles, Pampanga. Affiant exhibited to me his __________ ID with no.
_____________, as competent proof of his identity.

Doc. No.__________
Page No._________
Book No._________
Series of 2024