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    Affidavit of Insurance Claim

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    zee p
    1. The affiant owns a vehicle that was damaged in two separate incidents. 2. On one occasion, the affiant miscalculated while parking in his garage and bumped the rear side of the vehicle in the rain. 3. On another occasion, the affiant returned to his parked vehicle and noticed the left fog light cover was missing.

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    Affidavit of Insurance Claim

    Uploaded by

    zee p
    45 views1 page
    1. The affiant owns a vehicle that was damaged in two separate incidents. 2. On one occasion, the affiant miscalculated while parking in his garage and bumped the rear side of the vehicle in the rain. 3. On another occasion, the affiant returned to his parked vehicle and noticed the left fog light cover was missing.

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    Affidavit of Insurance Claim Sample

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    1. The affiant owns a vehicle that was damaged in two separate incidents. 2. On one occasion, the affiant miscalculated while parking in his garage and bumped the rear side of the vehicle in the rain. 3. On another occasion, the affiant returned to his parked vehicle and noticed the left fog light cover was missing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    45 views1 page

    Affidavit of Insurance Claim

    Uploaded by

    zee p
    1. The affiant owns a vehicle that was damaged in two separate incidents. 2. On one occasion, the affiant miscalculated while parking in his garage and bumped the rear side of the vehicle in the rain. 3. On another occasion, the affiant returned to his parked vehicle and noticed the left fog light cover was missing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Republic of the Philippines )

    City of Iloilo ) S.S.


    X--------------------------------------------------x

    AFFIDAVIT

    I, xxx, of legal age, married, Filipino and a resident of xxx, after being duly sworn to in accordance with
    law, hereby depose and state that:

    1. I am the registered owner of xxxx;

    2. On or about xxx (Saturday), 8:10 in the evening, while I was reverse parking my car to our small house
    garage, due to heavy rains, I miscalculated the position and the distance of my car against the post and
    bumped the right rear side of the car;

    3. Upon checking, I immediately noticed that the impact left damage specifically on the right rear side of my
    car;

    4. Furthermore, on xxx , around 6:30 in the evening, I went to xxx and parked at their parking lot. When I
    went back to my car, I noticed that one of the fog lights’ cover, specifically that on the left side of the
    vehicle was already missing and could no longer be found;

    5. Attached herein are photos of the xxx incident, marked as Annex “A”, photos of the xxx incident, marked
    as Annex “B”; and a photocopy of the Official Receipt and the Certificate of Registration (OR/CR) of my
    vehicle, marked as Annex “C”;

    6. As such, I am executing this Affidavit to attest to the truth of the foregoing and in order to recover
    insurance proceeds, and for whatever legal purposes this may serve

    IN WITNESS WHEREOF, I have hereunto set my hand this xxx at xxx

    xxx
    Affiant

    SUBSCRIBED AND SWORN to before me this xxx in xxx, the affiant xxx presented to me his xxx as his
    competent evidence of his identity.

    Doc. No. ____;


    Page No. ____;
    Book No. ____;
    Series of 2021.

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