REPUBLIC OF THE PHILIPPINES)

Province of Lanao del Norte ) S.S.

City of Iligan )
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AFFIDAVIT OF ACCIDENT

______, after having been dulysworn to in accordance with law,

hereby, depose and say that:

1. I am the authorized driver of one motor vehicle which is

particularly described as follows:

MAKE AND MODEL :

SERIAL NUMBER :
MOTOR NUMBER :
PLATE NUMBER :

2. On January 24, 2013 at around four o’clock in the afternoon, I was driving
along Airport Road at Parañaque City going southbound. In the same
lane, a ten-wheeler truck was also traversing the road on my right side on
a fast speed. As the truck was very fast, I did not immediately notice that
it sideswiped the right side portion of my driven vehicle.

3. Unfortunately, I was not able to stop the driver of the truck nor
get the plate number of the truck.

4. The accident happened so fast and went beyond my control. I am

executing this affidavit to attest to the truth of the foregoing statement
andin support of my claims for reimbursement from the insurance
company. _____________________

Affiant

SUBSCRIBED AND SWORN to before me this _______day of

_____________,20___ at ________________, Affiant exhibiting to me his/her
Residence Certificate No./ Valid Identification
_____________________________ issued at _____________ on
_____________________.

NOTARY PUBLIC
Doc. No. _______
Page No. _______
Book No._______
Series of _______