Vehicle Insurance Claim

Affidavit of Insurance Claim

I, ___________________________, of legal age, Filipino, ____________________, and presently residing at _____ _____________________________________, after having been duly sworn to in accordance with law, depose and state:

I am the owner of a certain registered motor vehicle, which I inherited from my deceased father through intestate succession, with the particular description as follows, to wit:

MAKE: Honda

BODY: Sedan


MODEL: 1998


Serial/Chassis No.: US15- 2B3509

MV FILE No.: 2477- 33438

On 03 October 2013 at 2 oçlock in the afternoon, th e said motor vehicle met an accident.

This had happened while i was parking in front of a hardware store between the two motor vehicles, at the left side was an elf van, and while at the right was a car. At that time, I was carefully looking at the car on my right, that I did not notice the elf van in the parking area. When I made a reverse turn, i hit the elf by my tail light and bumper

It is for that reason that i am executing this affidavit to file a claim for insurance.

I therefore have executed this Affidavit to attest the truth I mentioned herein and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _ day of __ 20____ in _, ___, Philippines.


Philippine Passport No. _

valid until _________ , 20_____