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Affidavit of Self-Accident (For Insurance Claim)

The affiant was driving their vehicle on July 08, 2023 when they accidentally backed into the basement parking wall, damaging the left rear bumper. They attest that the details in the affidavit are true for the purposes of an insurance claim. The affiant signed and swore to the affidavit before a notary public.

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gmcastillo051076
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1K views1 page

Affidavit of Self-Accident (For Insurance Claim)

The affiant was driving their vehicle on July 08, 2023 when they accidentally backed into the basement parking wall, damaging the left rear bumper. They attest that the details in the affidavit are true for the purposes of an insurance claim. The affiant signed and swore to the affidavit before a notary public.

Uploaded by

gmcastillo051076
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES )

______________ CITY ) S.S.


x----------------------------x

AFFIDAVIT

I, (COMPLETE NAME), Filipino, of legal age, single, and a resident of (Residential Address),
after being sworn to in accordance with law, do hereby depose and state that:

1. I am the holder of a Professional Driver’s License No. xxx-xx-xxxxx issued by the Land
Transportation Office, and valid until ________________;
2. At around 9:30 PM on July 08, 2023, I was driving a motor vehicle owned and registered in
my name which is more particularly described as follows:

Make: Engine No.:


Series: Chassis No.:
Body Type: Plate No.:
Year Model: MV File No.:

3. While I was maneuvering in reverse direction to park my car into my parking space at the
______________________, the aforementioned vehicle suddenly and accidentally hit the
basement parking wall which damaged the rear portion of the vehicle, more particularly the left
portion of the rear bumper;
4. I execute this Affidavit to attest to the truthfulness and veracity of the facts stated herein and
for insurance claim purposes and other legal purposes it will serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________ in


___________________________, Philippines.

COMPLETE NAME
Affiant

SUBSCRIBED AND SWORN to before me this ________________________ affiant exhibited


to me her Competent Evidence of Identity by way of Driver’s License No. xxx-xx-xxxxx issued
on July 07, 2023.

_________________________
Notary Public

Doc. No. _______;


Page No. _______;
Book No. _______;
Series of _______;

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