Republic of the Philippines)

City of Caloocan)S.S.

AFFIDAVIT OF ACCIDENT

I, AQUILIO D. DISMAS, Filipino, of legal age, with residence address at 101D

Asuncion St., Morning Breeze Subdivision, Caloocan City, Philippines, after having been
duly sworn to in accordance with law, hereby, depose and say that:

I am the authorized driver of one motor vehicle which is particularly described as

follows:

MAKE AND MODEL : Toyota Wigo Hatchback 2017

MV FILE NUMBER : 1380-00000861028
CHASIS NUMBER : MHKA 4DF 3FHJ025421
ENGINE NUMBER : 1KRA 389960
PLATE NUMBER : VV 6211

On July 4, 2017 at around 2:30 PM, I was driving at the left outermost lane along
EDSA Caloocan going to Balintawak, Quezon City. In the same lane, a motorcycle was
also traversing the road on my right side. As I was travelling at a moderate speed of 40
kph, a fast moving vehicle on the next lane to my right was trying to overtake, thus
causing the motorcycle to be almost sandwhiched between my driven vehicle and the
other vehicle. At that very moment, the driver of the motorcyle suddenly swerved to its
left. Immediately thereafter, the motorcylce and the other vehicle sped away. I did not
immediately notice that the motorcycle hit and sideswiped the right portion of my driven
vehicle. Unfortunately, I was not able to stop the driver of the motorcycle nor get the
plate number of the motorcycle. The accident happened so fast and went beyond my
control.

I am executing this affidavit to attest to the truth of the foregoing statement and in
support of my claims for the reimbursement from the insurance company.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 6 th day of

July 2017 at Caloocan City, Philippines.

AQUILIO D. DISMAS
Affiant

Before me, a notary public in and for the city named above, personally appeared
Aquilio D. Dismas with his Drivers License No. G03-96-035780 issued by the Land
Transportation Office, who was identified by me through competent evidence of identity
to be the same person who presented the foregoing instrument and signed the instrument
in my presence, and who took an oath before me as to such instrument.

Witness my hand and seal this 6th day of July 2017.

Doc. No. ____;

Page No. ____;
Book No.____;
Series of 2017.