Republic of the Philippines )

Province of Benguet ) S.S.

Municipality of La Trinidad )

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AFFIDAVIT OF ACCIDENT

I, Baro A. Menlaylayad, Filipino, of legal age, single and resident of JC 156, Pico, La Trinidad,
Benguet, Philippines, after having been sworn to in accordance with the law, depose and state:

1. That I am a duly licensed driver with Driver’s License No. M05-97-008645 which is valid until February
28, 2020.

2. That on December 21, 2018, at around 12 noon, I was driving a motor vehicle owned and registered in
my name which is more particularly described as follows:

Make : Izuzu Model : ELF 3.2 GLS AT

Chassis No. : MMBJRKB80AD022 Engine No. : 4M41UCAT7221
Plate No. : FBI 619 Year Model : 2015

3. That while I was driving along Halsema Highway in Tuba Benguet, the aforementioned vehicle was
bumped by a white van causing damage to its bumper and right fender.

4. That I am executing this Affidavit to attest to the truth of the foregoing and in support of my claim against
the insurer for the repair of the damage caused to my vehicle.

IN WITNESS THEREOF, I have hereunto set my hand this 27th day of December, 2018 in La
Trinidad, Benguet, Philippines.

BARO A. MENLAYLAYAD
Affiant

SUBSCRIBED AND SWORN TO ME this 27th day of December, 2018 in La Trinidad, Benguet,
Philippines, by BARO A. MENLAYLAYAD who presented her SSS ID No. 12244221, valid until March 31,
2021, issued in Baguio City, Philippines.

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