Insurance Claims
REPUBLIC OF THE PHILIPPINES)
CITY OF _______________) S.S.
AFFIDAVIT OF INSURANCE CLAIMS
I, _______________________________________, of legal age, Filipino, ____________, and presently residing at ________________ _________________________________________________, after having been duly sworn to in accordance with law, depose and state:
I am the owner of a certain registered motor vehicle, which I inherited from my deceased father through intestate succession, with the particular description as follows, to wit:
MAKE: Honda
BODY: Sedan
SERIES: Civic
MODEL: 1998
PLATE NO.: UTS 101
Serial/Chassis No.: US15- 2B3509
MV FILE No.: 2477- 33438
On 03 October 2013 at 2 oçlock in the afternoon, th e said motor vehicle met an accident.
This had happened while i was parking in front of a hardware store between the two motor vehicles, at the left side was an elf van, and while at the right was a car. At that time, I was carefully looking at the car on my right, that I did not notice the elf van in the parking area. When I made a reverse turn, i hit the elf by my tail light and bumper
It is for that reason that i am executing this affidavit to file a claim for insurance.
I therefore have executed this Affidavit to attest the truth I mentioned herein and for whatever legal purposes it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of __________ 20____ in ____________, __________, Philippines.
_______________________________________
Affiant
Philippine Passport No. ___________
valid until ____________ ____, 20____
SUBSCRIBED AND SWORN TO before me this ____ day of ___________ 20____ in _____________, _________, Philippines, affiant exhibiting to me her competent evidence of identity indicated below his above- stated name.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20____.