Skyland Plaza, Sen. Gil Puyat Ave cor Tindalo St.

, Makati City ∙ TIN: 000-487-306 VAT

P.O. Box 1893 MCPO 1258 Makati City ∙ Tel: (632) 581-5252 ∙ Email: customer.service@charterpingan.com

MOTOR VEHICLE ACCIDENT/LOSS REPORT

POLICY HOLDER
Name DrillCorp Philippines Inc. Policy No. MC-CLG-HO-16-001330-01
Mobile No. Telephone No. Email Address
09189792962 046-430-3517 cheryl@drillcorp.com
Address
16 South Coast Industrial Estate Bancal Carmona Cavite 4116
INSURED VEHICLE
ISF28S3161P89692243
Year and Model 2016/Pick up Make Type pICK uP Engine No.
Foton
Registered Owner Serial No. MVFile 0301-00000180124
Plate No.
DrillCorp Philippines Inc. ACM8942
DRIVER

Name Roberto G. Bialen License No. N14-81-020841 License Type Professional

Expiration Date 11/07/2018 Age 55 Address B12 L33 Ph2 mahogany St Celestin Brgy.Mainig Cabuyao

Is the Driver an employee of the Policyholder? YES NO If YES, in what capacity? ________________________________________
Company driver
ACCIDENT/LOSS DETAILS
Time CLEAR MODERATE POOR
Date of Accident/Loss
10/22/2017 abt 9:50am Visibility:
Address Name of Police Reported to PO2 Pedro Villamin Jr.
OTHER PARTICULARS

Purpose of Use Commercial use Who is to Blame for the Collision?

Direction Your Vehicle was Going Rate of Speed

Direction the Other Party was Going Not applicable Rate of Speed

PERSONS INJURED AND OTHER OCCUPANTS

Occupants of the Insured Vehicle:
NAME INJURED? MOBILE NO. EMAIL ADDRESS AGE
Roberto Bialen YES NO 09209171346 55

YES NO

YES NO
YES NO

YES NO

Occupants of the Other Vehicle:

NAME INJURED? MOBILE NO. EMAIL ADDRESS AGE
Not Applicable YES NO
YES NO

YES NO

YES NO
YES NO
Pedestrian:
NAME INJURED? MOBILE NO. EMAIL ADDRESS AGE
Not applicable YES NO
YES NO
 DAMAGE TO INSURED VEHICLE

Parts Damaged and Extent See pictures

Where Car May Be Seen

Front and side portion of the vehicle
ADVERSE VEHICLE/PROPERTY

Name of Owner Not Applicable Address

Name of Driver Address

Kind of Property
(If Vehicle, provide Year, Make, and Plate Number)
Not Applicable
Nature and Extent of Damage

Is Third Party Insured? YES NO If YES, provide the Name of the Company:________________________________________________
INDEPENDENT WITNESSES
Name Mobile No. Email Address

Name Mobile No. Email Address

Name Mobile No. Email Address

SKETCH AND BRIEF DESCRIPTION OF THE ACCIDENT

NOTE: Indicate your vehicle as “A”, other vehicle as “B”, etc. Provide Street names and direction and positions

Brief Description of Accident or Loss:

When driver arrived to Carmona Public Market and proceed to the parking lot, while parking he didn't noticed that there was a trash can in
front and he accidentally hit the trash can ,resulting to the damaged of the front portion of the Foton.

REQUIREMENTS SUBMITTED
Assured’s Requirements: Third Party Requirements:

Original Copy of Police Report and/or Duly

Original Copy of Repair Estimate
Notarized Affidavit
Original Copy of Repair Estimate Original Copy of Certificate of No Claim
Colored Pictures of Damaged Unit with Colored Pictures of Damaged Unit with
Plate Plate
Photocopy of Policy Photocopy of OR/CR

Photocopy of OR/CR Photocopy of Driver’s License with OR

Photocopy of Driver’s License with OR

NOTE: You may submit lacking requirements to claims.admin@axa.com.ph

Roberto Bialen
Cheryl D. Alsim/DrillCorp Philippines Inc.
Signature over Printed Name of Driver and Date Signature over Printed Name of Policy Holder and Date