Affidavit of Claim Against Insurance

REPUBLIC OF THE PHILIPPINES )                                                MAKATI CITY                           ) Sc.                         

A F F I D A V I T 

          I,  DIWATA AKOH , Filipino, single, of legal age, with residence at No. 143 IloveYou St., Barangay May Forever, Makati City, after having been duly sworn to in accordance with law, hereby depose and state that:

1.      I am the registered owner and driver of Ford Fiesta 2011 with Plate No. ABC 123;

2.      I drive and use the car daily as my service in going to my work in Quezon City and in attending to my clients in Metro Manila;

3.      On July 31, 2015, I parked my said car at ABC Mall In Quezon City, to attend a meeting with client;

3.      After more or less, two hours, I went back to the car and found out that the left side mirror and driver’s door were broken/damaged;

4.      I did not witness the incident and exerted my best effort to locate some witness or witnesses as to what happened and why my car was damaged but to no avail;

5.      That I am executing this affidavit to attest to the truthfulness of the foregoing statements/facts and for whatever legal purposes it may serve.

                  

IN WITNESS WHEREOF, I have hereunto set my hand this 31 July 2015 at Makati City, Philippines.

                                     

                                         DIWATA AKOH                                                                              Affiant

JURAT

SUBSCRIBED AND SWORN to before me this 31^ST of July 2015, affiant personally appeared and exhibited to me her LTO Driving License ID No. N02-12-1234-5678 issued on 16 June 2015 in Quezon City, Philippines.

NOTARY PUBLIC

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