REPUBLIC OF THE PHILIPPINES)

CITY OF BATANGAS )SS.

AFFIDAVIT OF ACCIDENT
I, NESTOR PHILLIP H. PUNZALAN, of legal age, Filipino citizen
and a resident of Batangas City after having duly sworn in accordance
with law hereby deposes and states that:

1. I am the registered owner of a vehicle which is particularly

described as follows:

Make : TOYOTA
Engine No. : 2KD5429288
Chassis No. : JTFJS02F-000025707
Body Type : VAN
Series : HIACE COMMUTER
Year Model : 2011
Plate No. : VFC475

2. On September 10, 2018 at around 4:00 in the morning, while I

was driving along the South Luzon Expressway, a stone suddenly
hit the windshield of said car;

3. Further, in the morning of September 12, 2018, while the above-

mentioned vehicle was parked beside our house in Santuray
Road, Batangas City, I noticed dents and scratches at the back
part of the vehicle;

4. The said vehicle is covered by an insurance policy of Prudential

Guarantee with Policy No. MC-PVC-HOM-0060115, period
covered from October 20, 2018 to October 30, 2018;

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

foregoing, for the purpose of informing the insurer of such
occurrence and further, for whatever legal purpose this may
serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this September 19,2018 at Batangas City.

NESTOR PHILLIP H. PUNZALAN

Affiant

SUBSCRIBED AND SWORN to before me in the City of

Batangas this 19th of September 2018 by the Affiant who exhibiting to
me her Professional Driver’s License with No. D01-92-068739.

Doc. No. 134A;

Page No. 28;
Book No.XXI;
Series of 2018.