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    Affidavit of Self Accident

    Uploaded by

    Chow P. Cuevas
    The affidavit describes a traffic accident that occurred on November 9, 2019 in San Matias, Guagua, Pampanga, Philippines. The driver, who was operating a 2002 Honda motorcycle with side car registered under his name, felt dizzy and lost consciousness, colliding with a metal fence in the middle of the road near a Petron gas station while traveling towards the Diosdado P. Macapagal Memorial Hospital. He executed the affidavit to attest to the truth of the events and in support of an insurance claim to repair the damage caused to his vehicle.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Affidavit of Self Accident

    Uploaded by

    Chow P. Cuevas
    346 views2 pages
    The affidavit describes a traffic accident that occurred on November 9, 2019 in San Matias, Guagua, Pampanga, Philippines. The driver, who was operating a 2002 Honda motorcycle with side car registered under his name, felt dizzy and lost consciousness, colliding with a metal fence in the middle of the road near a Petron gas station while traveling towards the Diosdado P. Macapagal Memorial Hospital. He executed the affidavit to attest to the truth of the events and in support of an insurance claim to repair the damage caused to his vehicle.

    Original Description:

    Simple affidavit of self accident

    Original Title

    Affidavit of self accident

    Copyright

    © © All Rights Reserved

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    The affidavit describes a traffic accident that occurred on November 9, 2019 in San Matias, Guagua, Pampanga, Philippines. The driver, who was operating a 2002 Honda motorcycle with side car registered under his name, felt dizzy and lost consciousness, colliding with a metal fence in the middle of the road near a Petron gas station while traveling towards the Diosdado P. Macapagal Memorial Hospital. He executed the affidavit to attest to the truth of the events and in support of an insurance claim to repair the damage caused to his vehicle.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    346 views2 pages

    Affidavit of Self Accident

    Uploaded by

    Chow P. Cuevas
    The affidavit describes a traffic accident that occurred on November 9, 2019 in San Matias, Guagua, Pampanga, Philippines. The driver, who was operating a 2002 Honda motorcycle with side car registered under his name, felt dizzy and lost consciousness, colliding with a metal fence in the middle of the road near a Petron gas station while traveling towards the Diosdado P. Macapagal Memorial Hospital. He executed the affidavit to attest to the truth of the events and in support of an insurance claim to repair the damage caused to his vehicle.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    REPUBLIC OF THE PHILIPPINES)

    MUNICIPALITY OF GUAGUA)
    Province of Pampanga ) S.S.
    x-------------------------------------x

    AFFIDAVIT OF DRIVER
    I, XXXXXXXXXXXXXXXXXX of legal age, Filipino, widower and a resident
    of 442 Bancal, Guagua, Pampanga, after having been duly sworn to in
    accordance with law, depose and state THAT:

    1. That I am a duly licensed driver with Driver's License No.


    XXXXXXXXXXXXX, which is valid until September 6, 2022.

    2. That on November 9, 2019, at around 10:21pm, I was driving a motor


    vehicle owned and registered in the name of by XXXXXXXXXXX which is
    more particularly described as follows:

    a. Make: Honda Motorcycle with Side Car


    b. Plate No: XXXXXXXxx
    c. Engine Number: XXXXXXXXXXXx
    d. Chassis Number: XXXXXXXXXXXXx
    e. Year: 2002

    3. I was driving in San Matias, Guagua, Pampanga, near Petron Gas Station.
    I was going in the direction towards the Diosdado P. Macapagal
    Memorial Hospital. I suddenly felt dizzy and lost consciousness. I did
    not know that I collided with the metal fence/barrier in the middle of
    the road.

    4. As proof, I have attached a copy of the traffic accident report issued by


    the Guagua PNP. It is marked as Annex A.

    5. That I am executing this Affidavit to attest to the truth of the forgoing


    and in support of the claim against the insurer for the repair of the
    damage caused to my vehicle

    IN WITNESS WHEREOF, I have hereunto set my hand this November 27,


    2019 in Guagua, Pampanga, Philippines.

    XXXXXXXXXXXXXXXXXXXXx
    Affiant

    1|Page
    SUBSCRIBED AND SWORN to before me this November 27, 2019 in
    Guagua, Pampanga. Affiants exhibited to me his Driver’s License with
    no.XXXXXXXXXXXXXXXXXXX bearing their picture and signature.

    WITNESS MY HAND AND SEAL OF OUR OFFICE.

    CONTROL No.
    XXXXXXXXXXXXXXXXXx
    XXXXXXXXXXXXXXXXXXXX
    XXXXXXXXXXXXXX
    (Pursuant to R.A. No. 9406)

    2|Page

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