REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAGAYAN ) S.S.

CITY TUGUEGARAO )

AFFIDAVIT OF AUTHORIZED DRIVER

 

I, ROEL C. ESCOBAR, Filipino, of legal age, and a resident of Gosi Sur, Tuguegarao
City, after having been duly sworn in accordance with law, hereby state that:

1. I am the designated office driver of Department of Labor Employment Region 02

official vehicle bearing plate number SAA 4642;

2. The said vehicle figured in an accident while I was driving it, the details of which as
follow:

“On April 16, 2019 at around 8:45 in the morning, our team were on board
of Toyota Innova bearing plate no. SAA 4642 being cautiously driven by
Mr. Roel Escobar. While we were traversing the National Highway Road at
Pata, Tuao, and Cagayan heading towards LGU Piat, our driver signaled
left and cautiously overtook a TMX 155 motorcycle bearing plate no.
0244707 driven by Mr. DOMINGO M. ELCHICO since the road was clear.
And as we reach that point near the curve area of the highway and heading
towards the west direction, we were surprised when the motorcycle, after
being overtaken, incautiously swerved left causing it to hit the right side of
our vehicle. The motorcycle fell on the ground thus, injuring the driver. We
immediately checked on the condition of the driver and upon knowing that
he is conscious, our team hurriedly rushed him to the nearest hospital, the
Nuestra Senora de Piat Hospital, to provide him with proper medication. At
the hospital, the doctor informed us that the driver has sustained only minor
injuries. After the incident, we went to Tuao Police station to report the
accident.”

3. I am executing this affidavit for the purpose of processing our claims against the
insurance of the said vehicle of GSIS;

4. I aver to the truth of the foregoing. 

IN WITNESS WHEREOF, I hereby set my hand, this __ day of April 2019, at the City
of Tuguegarao, Cagayan.

ROEL C. ESCOBAR

Affiant

SUBSCRIBED AND SWORN to before me, this __ day of April 2019, at the City of
Tuguegarao, Cagayan. Affiant executing to me his Driver’s License bearing
number________________ as proof of his identity.

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of 2019.