Republic of the Philippines)

City of Taguig) S.S.

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

AFFIDAVIT OF DAMAGE VEHICLE

I, _______________________ , Filipino, of legal age, married and a resident of (address) ,

Philippines, after being sworn to in accordance with law, depose and state:

1. That I am a duly licensed driver with Driver’s License No. ____________ , which is valid until
_____________;

2. That on 17 March 2018, at around _______ , I was driving a motor vehicle owned and registered
in my name which is more particularly described as follows:

Make: Model:
Chassis No. Engine No.:
Plate No. Year Model:

3. That while I was driving along Epifanio de los Santos Avenue (EDSA), suddenly the
aforementioned vehicle was bumped by a speeding motorcycle and hit the side mirror of the
vehicle. As a result, the entire side mirror broke off from the vehicle’s body;

4. That there were no traffic enforcers at the time of the accident;

5. That I am executing this Affidavit to attest to the truth of the foregoing and in support of the
claim against the insurer for the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this _________ day of March, 2018 in the City
of _____________, Philippines.