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Affidavit of Damage

The affidavit describes damage to a Toyota Avanza vehicle. The owner states that on October 9, 2017 while entering a premises, they did not notice a small tree on the pavement and ran over it. This caused the tree to hit and damage the vehicle's right side headlights and bumper. The affidavit is being executed to substantiate an insurance claim for the damage with People's General Insurance Corporation.

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Bong Roque
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633 views1 page

Affidavit of Damage

The affidavit describes damage to a Toyota Avanza vehicle. The owner states that on October 9, 2017 while entering a premises, they did not notice a small tree on the pavement and ran over it. This caused the tree to hit and damage the vehicle's right side headlights and bumper. The affidavit is being executed to substantiate an insurance claim for the damage with People's General Insurance Corporation.

Uploaded by

Bong Roque
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

AFFIDAVIT OF DAMAGE

I, ________________, of legal age, Filipino and with postal address at


____________________, after being duly sworn in accordance with law, do hereby
depose and state:

1. I am the registered owner of a motor vehicle, more particularly described as


follows:
Make: Toyota Avanza 1.3E AT
Color: Champagne Metallic
Model: ________
Plate No.: ___________
CR No.: __________

2. Last October 9, 2017 at around 7:00pm, as I entered the premises of


________________, I did not notice that a small tree was on the pavement. When I ran
over the tree, I heard a loud thud underneath the vehicle. In my panic, I stepped on the
gas pedal instead of the brakes.

3. As a consequence, the tree hit and damaged the vehicle’s right side
headlights, as well as the bumper.

4. I am executing this affidavit to attest to the truth of the foregoing and for the
purpose of substantiating the claim for damage with People’s General Insurance
Corporation.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of


__________, 20___ in _________________.

Affiant

Republic of the Philippines }


City of San Fernando, Pampanga } S.S.
x--------------------------------------------x

SUBSCRIBED AND SWORN TO BEFORE ME this _____ day of ________,


20___, affiant exhibiting to me his Driver’s License No. _____________________
expiring on ________________.

WITNESS MY HAND AND NOTARIAL SEAL on the date and at the place first
above-written.

Notary Public

Doc. No. ____


Page No. ____
Book No. ____
Series of 20___.

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