REPUBLIC OF THE PHILIPPINES)

CITY OF DAVAO) S.S.

X-------------------------------------x

AFFIDAVIT
I, _______________________________________, of legal age, Filipino, ____________,
and presently residing at _____________________________________________________,
after having been duly sworn to in accordance with law, depose and
state:

1. That I am the [Relationship with the Deceased] of [NAME OF

DECEASED] who died on [Date] in [Place] because of [Reason of
Death] as per autopsy result conducted by Dr. [Name of Doctor];
2. That per investigation of the Quezon City Police Station, my
husband was driving along the northbound lane of EDSA in front
of Camp Aguinaldo in Quezon City when he was hit/bumped by a
truck coming from the opposite direction; copy of the Traffic
Investigation Report is hereto attached as Annex "A";
3. That at the time of the incident, my husband was a duly licensed
driver carrying Driver's License No. 123456 and was riding on a
Toyota Innova, gray in color and with Plate No. XYZ-123 owned by
me with Certificate of Registration No. 55667788;
4. That I am executing this affidavit in support of my application for
insurance claim with [Name of Insurer], to attest to the truth of
the foregoing, and for whatever legal purposes it may serve.

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

__________ 20____ in ____________, __________, Philippines.

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at

________________ affiant exhibited to his/her competent evidence of
identity by way of _________________ issued on ____________ ____, 20____ and
valid until ____________ ____, 20____ in _______________, Philippines.

1 of 1