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Affidavit of Accident

Regie C. Palsis files an affidavit stating that on January 9, 2020, he parked his Toyota Wigo vehicle in front of Mandurriao Plaza in Iloilo City. When he returned after 30 minutes, bystanders informed him that his vehicle had been hit by a passing tricycle, which then fled the scene. As a result, Palsis' vehicle sustained scratches and damage. Unfortunately, the bystanders did not get the tricycle's license plate number. Palsis executes this affidavit to support an insurance claim for reimbursement for the damages to his vehicle.

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993 views

Affidavit of Accident

Regie C. Palsis files an affidavit stating that on January 9, 2020, he parked his Toyota Wigo vehicle in front of Mandurriao Plaza in Iloilo City. When he returned after 30 minutes, bystanders informed him that his vehicle had been hit by a passing tricycle, which then fled the scene. As a result, Palsis' vehicle sustained scratches and damage. Unfortunately, the bystanders did not get the tricycle's license plate number. Palsis executes this affidavit to support an insurance claim for reimbursement for the damages to his vehicle.

Uploaded by

Maharshi Cru
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.


x-----------------------------------------x

AFFIDAVIT OF ACCIDENT
(RE: DRIVER’S AFFIDAVIT)

I, REGIE C. PALSIS, of legal age, married, and Filipino and resident of Calahunan,
Mandurriao, Iloilo City, after having duly sworn in accordance with law hereby depose
and say:

That I am a Non-Professional holder and the driver of one motor vehicle


registered in the name of my wife MARIA HARLENE PALSIS, and particularly described
as follows:

CR NO.: 349950484
MAKE AND MODEL: TOYOTA WIGO 1.0 G MT, HATCHBACK
ENGINE NUMBER: 1KRA493998
CHASSIS NUMBER:MHKA4DE5FKJ009859
PLATE NUMBER:

On 09 January 2020 at about 7:30 in the morning, I parked the above-described


motor vehicle in front of Mandurriao Plaza, Mandurriao, Iloilo City. I crossed the street
and went inside the Mandurriao Public Market. After thirty (30) minutes, when I
returned to the place where I left the car, I was informed by the by-standers that the
aforesaid car was hit by a tricycle and the latter immediately left. As a result, the
above-mentioned motor vehicle incurred scratches and damages.
Unfortunately, the by-standers failed to get the plate number of the tricycle.
I am executing this affidavit to attest to the truth of the foregoing statement
and in support the claims for reimbursement from the insurance company.

IN WITNESS WHEREOF, we hereby set my hand this ______________ at City of


Iloilo, Philippines.

REGIE C. PALSIS
Affiant
PDL No. F12-19-003098
Valid until 2024/05/09

SUBSCRIBED AND SWORN to before me this ______________ at City of Iloilo,


Philippines, affiant was identified by me through competent evidence of identity
described under his name.

Doc. No. _____;


Page No. _____;
Book No._____;
Series of 2020.

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