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Affidavit of Accident for Insurance

Ma. Victoria P. Libunao was involved in a vehicular accident on August 5, 2016 in Naga City. While backing her vehicle out of her garage, she miscalculated the distance and hit the wall of the garage. She then hit the back of a parked car on the street due to heavy rain reducing her visibility. Photos were taken to document the damages to both vehicles. Libunao signed an affidavit to attest to the details of the accidental collision and to file an insurance claim with Standard Insurance Corp.

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156 views1 page

Affidavit of Accident for Insurance

Ma. Victoria P. Libunao was involved in a vehicular accident on August 5, 2016 in Naga City. While backing her vehicle out of her garage, she miscalculated the distance and hit the wall of the garage. She then hit the back of a parked car on the street due to heavy rain reducing her visibility. Photos were taken to document the damages to both vehicles. Libunao signed an affidavit to attest to the details of the accidental collision and to file an insurance claim with Standard Insurance Corp.

Uploaded by

Cuki Isbusy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines }

City of _________________ } S.S.

AFFIDAVIT OF ACCIDENT
I, MA. VICTORIA P. LIBUNAO Filipino, single, of legal age and
with residence address at Unit 214 Maraca building Rhapsody
Residences Brgy. Cupang Muntinlupa City after having been duly
sworn to in accordance with law do hereby depose and say that:
1. I am the registered owner of one motor vehicle particularly
described as follows:
Make
:
Chassis No.
Plate No. :
Color
:

:
EG 1514

2. On or about 5 August 2016, at around 1:00 PM, I was driving the


above-described motor vehicle along Begonia Street Jardin Real
Naga City and while executing a reverse going out of the garage my
right rear hit the wall Moreover, while I was backing out I did not
notice that I was very close to the passenger vehicle parked along
the street and eventually hit the back portion of the car. As a result
thereof, the said vehicle sustained damages as shown in the various
photos attached and made an integral part of this affidavit;
3. The above-said vehicular accident resulted from my miscalculation
of the distance and heavy rain;
4. I have no intention whatsoever to purposely cause damage on my
vehicle and the vehicular mishap mentioned above was purely
accidental in nature;
5. I am executing this affidavit to attest to the truth of the foregoing
and for purposes of filing an insurance claim with Standard
Insurance Corp.

MA. VICTORIA P. LIBUNAO


Affiant
SUBSCRIBED AND SWORN TO before me this ____ day of July
2015, affiant exhibited to her Drivers License (ID) No.
Doc No. ______
Page No. _____
Book No. _____
Series of 2015

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