Republic of the Philippines]

City of Legazpi ] s.s.

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

AFFIDAVIT OF INSURANCE
I, ALFONSO CO TAN, of legal age, Filipino citizen and with address at Felipe II Street,
Daet, Camarines Norte, after having been duly sworn to in accordance with law, do hereby
depose and states that:
1. I am the duly registered owner of Mitsubishi Mirage with plate number EBY 648
and more particularly described as follows:

Make: Mitsubishi Year Model: 2013

Engine No.: 3A92UAL2805 Frame No.: MMBXNA03ADH010238
Model No.: Mirage GLX 1.26 Plate No.: EBY 648
2. That on September 6, 2018 around 9:00 o’clock in the evening, while my
Mitsubishi Mirage was parked at Mayon Avenue, Naga City, it was hit by a tricycle
vehicle according to some witnesses, which caused deformity on the driver’s side
of the said car.
3. I am executing this Affidavit to attest to the truth of the foregoing statement and
in purposes of insurance claim.

IN WITNESS WHEREOF, I have hereunto set my hand this 17th day of September 2018
at Legazpi City, Philippines.

ALFONSO CO TAN
Affiant
ID No. _________________
Issued by ______________

SUBSCRIBED AND SWORN to before me this 17th day of September 2018 at Legazpi
City, Philippines, affiant exhibited himself to me his identification card indicated below his
name bearing his photograph and genuine signature as competent proof of his identity
pursuant to the 2004 Rules on Notarial Practice.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018.