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Republic of the Philippines)

Province of Quezon )S.S.


City of Lucena )

AFFIDAVIT OF ACCIDENT

I, FRANCES DYAN T. LIM, of legal age, single, and a resident of 27 Jasmin St.
Gloria III Subdivision, Brgy. Culiat, Tandang Sora, Quezon City, Philippines, after being
sworn to in accordance with law, depose and state:

1. That I am the duly registered owner of a motor vehicle more particularly


described as follows:

Make: Ford
Series: Ecosport 5DR TR
Year Model: 2017
Engine No: UEJAHM82341
Chassis No: MPBSXXMXKSHM82341
Certificate of Registration No.: 284582406 dated 08/01/2017
Official Receipt No.: 1218564115 dated 08/01/2017

2. That on 06 August 2017 (Sunday), at around 4:00pm, I was in the


passenger seat of my motor vehicle as it was being driven by my companion, JAN
MICHAEL O. BORJA, through the length of the South Luzon Expressway (SLEX) bound
from Quezon City to Tayabas City, Quezon, when a sharp stone suddenly and
accidentally hit the windshield of the aforementioned vehicle with ample force and as a
result sustained a bulls-eye crack in the windshield;

3. That at the time of the incident, I authorized my companion, JAN


MICHAEL O. BORJA, a resident of B6 L2 Carmen Homes, San Pedro, Laguna, to drive
the vehicle and he is a duly licensed driver with Drivers License No. N2602009081,
which is valid until 02 May 2022.

4. That I am executing this Affidavit to attest to the truth of the foregoing and
in support of the claim upon the insurer for the repair of the damage caused to my
vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________,


in the City of Lucena, Quezon, Philippines.

_____________________
Frances Dyan T. Lim

SUBSCRIBED AND SWORN to before me, this _____________, 2017 in the


City of Lucena, Quezon, Philippines, by Frances Dyan T. Lim, who exhibited to me her
Integrated Bar of the Philippines (IBP) I.D. with Roll of Attorneys No. 63546.

Doc. No.:______;
Page No:______;
Book No:______;
Series of 2017.

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