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AFFIDAVIT - Insurance Glass Broken

Juan Dela Cruz files an affidavit stating that on February 6, 2024 while driving his silver 2023 Utility Vehicle Wagon, plate number DBN9154, hard objects struck and broke the front windshield. He executes this affidavit to inform his insurance company of the incident to file an insurance claim and to attest to the truth of the events.

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173 views1 page

AFFIDAVIT - Insurance Glass Broken

Juan Dela Cruz files an affidavit stating that on February 6, 2024 while driving his silver 2023 Utility Vehicle Wagon, plate number DBN9154, hard objects struck and broke the front windshield. He executes this affidavit to inform his insurance company of the incident to file an insurance claim and to attest to the truth of the events.

Uploaded by

olive pareja
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Republic of the Philippines )

AFFIDAVIT

I, JUAN DELA CRUZ Filipino, of legal age, Blk 16 Lot 9 PH 4 Lancaster Residences, Alapan II-A, Imus City
4103 Cavite, after having been duly sworn to an oath in accordance with law, do hereby depose and say:

1. That I am the registered OWNER of certain vehicle described as follows:

Vehicle Type: Utility Vehicle WAGON


Color Type: SILVER METALLIC 1
File No: 040124000882456
Year Model: 2023
Plate No: DBN9154

2. That in the afternoon of February 6, 2024 while I was on my way going to my residence, driving the said
vehicle, some hard/stone objects from nowhere hit the front windshield glass of the vehicle;

3. That due to said impact, the vehicle’s front windshield glass were broken and damaged;

3. That I am executing this affidavit to inform the insurance entity about such incident as one of the
requirements for insurance claim;

4. That I am executing this affidavit to attest to the truth of the foregoing facts and for all other legal intents and
purposes this may serve.

IN WITNESS WHEREOF, I have hereto set my hand this _____ day of February , 2024 in Tanza, Cavite,
Philippines.

JUAN DELA CRUZ


Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ____________ in _______________________,


Philippines. Affiant exhibited to me her __________________________________________________ as
competent evidence of her identity.

Doc No. _______;


Page No. _______;
Book No. ________;
Series of 2024

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