Republic of the Philippines)

CITY OF DAVAO . . . . . ..)S.S.

X ----------------X

AFFIDAVIT OF ACCIDENT
I, SARAH A. SURIBAS, of legal age, Filipino and a resident of
Km. 19 Los Amigos, Tugbok, Davao City, and UNDER OATH do hereby
depose and say:
That I am the true, lawful and absolute owner of a TOYOTA
HILUX, Metallic Green - color bearing Plate No. LGT-248.
That sometimes on March 16, 2010 at around 4:30 P.M. while I
parked in the parking Lot of SM Ecoland . I accidentally bumped while I
was backing my vehicle.
That when I came back and as I was about to board my car, I
evidently found numerous visible damages around its body, which was
never there when I parked the said vehicle.
That upon careful scrutiny, I saw that the SIDE PANEL of
vehicle and scratched rear bumper.

my

That after thorough inquiry among by standers nearby, it was

evident that my vehicle was damaged for reasons beyond my control.
That I have executed the foregoing statements to be true and
correct for purposes of seeking indemnification for damages incurred.
IN WITNESS WHEREOF, I have hereunto affixed my signature
this ____ day of _______________ at Davao City, Philippines.

SARAH A. SURIBAS
Affiant
SUBSCRIBED AND SWORN TO before
__________________ at Davao City, Philippines.

me

this

____

day

of

Republic of the Philippines)

CITY OF DAVAO . . . . . ..)S.S.
X ----------------X
AFFIDAVIT OF ACCIDENT
I, MARCELINO PARUNGAO, JR., of legal age, Filipino, and a
resident of 777 Dacudao Ave., Agdao, Davao City, Philippines, and
UNDER OATH do hereby depose and say:
That I am the owner/driver of a certain of motor vehicle,
particularly described as follows:
Make
Plate No.
Model

:
:

TOYOTA VIOS 1.3e

LGM526
:
2009

That sometimes on September 16, 2009 at around 2:45 P.M., I

was driving the said vehicle from our garage I accidentally hit our gate
and the left side mirror of the said vehicle bang to the gate which
cause the damage;
That I am executing this affidavit to attest to the truth and to
inform the proper authorities concerned and for whatever legal
purpose this may serve.
IN TRUTH WHEREOF, I have hereunto affixed my signature this
________day of _____________, at Davao City, Philippines.

MARCELINO PARUNGAO, JR.

Affiant
SUBSCRIBED AND SWORN to before me this _____ day of
____________________, at Davao City, Philippines.

Republic of the Philippines)

CITY OF DAVAO . . . . . ..)S.S.

X ----------------X
AFFIDAVIT OF ACCIDENT
I, EDUARDO H. AQUILINO, of legal age, Filipino, Single and a
resident of #133 Ladislawa Ave., Buhangin, Davao City, Philippines,
UNDER OATH do hereby depose and say:
That I am a policy holder with No. GAC/08-P0064250 of Generali
Pilipinas Insurance Corporation, Davao City;
That sometimes on January 4, 2009 at around 03:00 A.M. I was
with my friend whose driving the vehicle whom we agreed to buy some
goods in Agdao Public Market, along the way, in a blink of an eye a dog
crossed along the way which my friend wasnt able to maneuver and
unexpectedly that causes my physical incapability to work due to the
physical damages I acquires on the said accident;
That the doctor examined me, and the findings are as follows:
a. Abrasion on the left eyebrow
b. STC Lower eyelid
c. Abrasions on the left hand and forearm, left dorsal aspect on
the hand left knee;
That I am executing this affidavit to attest to the truth and to
inform the proper authorities concerned, the Generali Pilipinas
Insurance Corporation and for whatever legal purpose this may serve.
IN TRUTH WHEREOF, I have hereunto affixed my signature this
________day of _____________, at Davao City, Philippines.

EDUARDO H. AQUILINO
Affiant
SUBSCRIBED AND SWORN to before me this _____ day of
____________________, at Davao City, Philippines.

Republic of the Philippines)

CITY OF DAVAO . . . . . ..)S.S.
X ----------------X

AFFIDAVIT OF ACCIDENT

I, SARAH A. SURIBAS of legal age, married, Filipino, and a

resident of Km. 19 Los Amigos,Tugbok, Davao City, Philippines, UNDER
OATH do hereby depose and say:
That I am the registered owner of a certain TOYOTA HILUX
bearing with Plate No. LGT-248;
That sometimes on March 16, 2010 at around 4:30 P.M. I was
backing my said vehicle in the SM Parking Area, I accidentally bumped
my vehicle that sustained damage at the REAR SIDE PANEL BUMPER
when it hit the post in the parking Lot at SM, Ecoland Davao City.
That after thorough inquiry, it was evident that my vehicle was
damaged for reasons beyond my control.
That I am executing this affidavit to attest to the truth and to
inform the proper authorities concerned and for whatever legal
purpose this may serve.
IN TRUTH WHEREOF, I have hereunto affix my signature this
________day of _____________, at Davao City, Philippines.

SARAH A. SURIBAS
Affiant
SUBSCRIBED AND SWORN to before me this _____ day of
____________________, at Davao City, Philippines.

Republic of the Philippines)

CITY OF DAVAO . . . . . ..)S.S.
X ----------------X

AFFIDAVIT OF ACCIDENT
I, CHRISMA V. PELIMER, of legal age, married, Filipino, and a
resident of Blk. 11 Lot 27 Paseo C. Solariega, Davao City, Philippines,
UNDER OATH do hereby depose and say:
That I am the registered owner of a certain VIOS IS Toyota
bearing with Plate No. LFY-702;
That sometime on April 14, 2010 at around 10:30 A.M. I was
parking my said vehicle in the SM Parking Lot Area, I accidentally
bumped my vehicle that sustained damage where the LOWER PART OF
THE FRONT BUMPER was cracked.
That after thorough inquiry, it was evident that my vehicle was
damaged for reasons beyond my control.
That I am executing this affidavit to attest to the truth and to
inform the proper authorities concerned and for whatever legal
purpose this may serve.
IN TRUTH WHEREOF, I have hereunto affixed my signature this
________day of _____________, at Davao City, Philippines.

CHRISMA V. PELIMER
Affiant
SUBSCRIBED AND SWORN to before me this _____ day of
____________________, at Davao City, Philippines.

Republic of the Philippines)

CITY OF DAVAO . . . . . ..)S.S.
X ----------------X

AFFIDAVIT OF ACCIDENT
I, GENEVIVE P. ALCALA, of legal age, Filipino, and a resident of
#16 Lilac St., Phase 4-A El Rio Vista Subd., Bacaca, Davao City,
Philippines, UNDER OATH do hereby depose and say:
That I am the registered owner of a certain 1.3 E VIOS Toyota
bearing with Plate No. LGM 436;
That sometime on May 25, 2010 at around 5:30 P.M. I was
entering the gate toward the parking area of my residence, I
accidentally hit the gate with my vehicle where the RIGHT SIDE OF THE
PASSENGER DOOR sustained damage.
That after thorough inquiry, it was evident that my vehicle was
damaged for reasons beyond my control.
That I am executing this affidavit to attest to the truth and to
inform the proper authorities concerned and for whatever legal
purpose this may serve.
IN TRUTH WHEREOF, I have hereunto affixed my signature this
________day of _____________, at Davao City, Philippines.

GENEVIVE P. ALCALA
Affiant
SUBSCRIBED AND SWORN to before me this _____ day of
____________________, at Davao City, Philippines.

Republic of the Philippines)

CITY OF DAVAO . . . . . ..)S.S.
X ----------------X

AFFIDAVIT OF DAMAGE
I, SHAHRIZA APRIL NOR-GASCON, of legal age, Filipino, and
currently residing at #35 Cordillera Street Phase II Central Park
Subdivision, Bangkal, Davao City, Philippines, UNDER OATH do hereby
depose and say:
That I am a former resident of Block 10 Lot 17 Anturium Street,
NHA Phase I Bangkal, Davao City;
That sometime on June 28, 2011, around 11:30 in the evening,
our area was one of those under the state of calamity because of the
flashflood incident;
That due to the flashflood, my pertinent papers such as my
Nursing Board Certificate and College Diploma duly issued by Dr.
Domingo B. Tamondong Memorial School Incorporated were destroyed
for reasons beyond control;
That I am executing this affidavit to attest to the truth and to
inform the proper authorities concerned and for whatever legal
purpose this may serve.
IN TRUTH WHEREOF, I have hereunto affixed my signature this
________day of _____________, at Davao City, Philippines.

SHAHRIZA APRIL NOR-GASCON

Affiant
SUBSCRIBED AND SWORN to before me this _____ day of
____________________, at Davao City, Philippines.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2011;