Affidavit of Death Due to Vehicle Accident for Insurance Claim

(Affidavit of Death Due to Vehicle Accident for Insurance Claim)

Republic of the Philippines)
Province of_________________) S.S.
City/Municipality of_____________)
x – – – – – – – – – – – – – x


I,____________,legal age, widow and a resident of____________, Philippines, after having been duly sworn to in accordance with law, do hereby depose and state the following:

That I am the (widow/widower)of____________;

That my (husband/wife) died on_____________because of_____________injuries sustained in a vehicular accident as per the results of the autopsy conducted by Dr.____________;

That per investigation of the_____________Police Station, my (husband/wife) died as a result of a vehicular accident at ____________ when while he was_____________, he was bumped / hit by a truck coming from the opposite direction;

That my husband was a duly licensed driver at the time of the incident and was carrying Driver’s License No.____________and was riding on a_____________,_____________in color and with Plate No._____________owned by _____________with Certificate of Registration No._____________;

That I am executing this affidavit to attest to the truth of the foregoing and for whatever legal purposes that this statement may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this_____________, in the City of_____________, Philippines.