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
SUBSCRIBED AND SWORN to before me this 31ST 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.
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