Affidavit of accident

for record and insurance purposes

1. Republic of the Philippines)
___________________ ) S.S.
___________________ )

AFFIDAVIT OF ACCIDENT


I, _________________, Filipino, of legal age, married/single, and a resident of
________________, Philippines, after being sworn to in accordance with law, hereby
depose and state:
1. That I am a holder of a Professional Driver’s License with No. ____________, valid
until ____________________;
2. That on ___________ at around _____________, I was driving a
__________________, owned and registered in the name of ________________
towards _________________________;
3. That the abovementioned vehicle is more particularly described as follows:
Make : Engine No. :
Series : Chassis No. :
Body Type : Plate No. :
Year Model : MV File No. :
4. That upon reaching at the slightly ascending road along the _______________, a
filtered stone from unidentified vehicle coming from the opposite direction
accidentally hit the windshield of the above described vehicle which resulted to a
visible damaged/ cracked as shown by the herein attached photo marked as Annex
“B”;
5. That I reported the said incident at the _________ Police Station for record and
reference purposes. Copy of the Traffic Blotter is hereto attached and marked as
Annex “C”;
6. That I am executing this Affidavit to attest to the truth of the forgoing and in support
of the claim from the insurer for the repair of the damage caused to the said vehicle
and for whatever legal purpose or worth it may serve best.
IN WITNESS WHEREOF , I have hereunto set my hand this _______________ in
_________________, Philippines.

_________________________
AFFIANT


SUBSCRIBED AND SWORN TO BEFORE ME this ________________ in
_____________________. Affiant exhibited to me his Driver’s License I.D with No.
indicated above.


Doc. No. ________;
Page No. ________;
Book No. ________;
Series of 20____.