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    Affidavit of Accident

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    franceslim24
    Frances Dyan T. Lim files an affidavit of accident regarding damage to her 2017 Ford Ecosport vehicle. On August 6, 2017 while driving on the South Luzon Expressway with her companion Jan Michael O. Borja, a sharp stone hit the windshield, causing a bulls-eye crack. At the time of the incident, Borja was driving the vehicle with Lim's authorization as a licensed driver. Lim executes this affidavit to attest to the truth of the incident and in support of an insurance claim to repair the damage.

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    Affidavit of Accident

    Uploaded by

    franceslim24
    138 views1 page
    Frances Dyan T. Lim files an affidavit of accident regarding damage to her 2017 Ford Ecosport vehicle. On August 6, 2017 while driving on the South Luzon Expressway with her companion Jan Michael O. Borja, a sharp stone hit the windshield, causing a bulls-eye crack. At the time of the incident, Borja was driving the vehicle with Lim's authorization as a licensed driver. Lim executes this affidavit to attest to the truth of the incident and in support of an insurance claim to repair the damage.

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    Frances Dyan T. Lim files an affidavit of accident regarding damage to her 2017 Ford Ecosport vehicle. On August 6, 2017 while driving on the South Luzon Expressway with her companion Jan Michael O. Borja, a sharp stone hit the windshield, causing a bulls-eye crack. At the time of the incident, Borja was driving the vehicle with Lim's authorization as a licensed driver. Lim executes this affidavit to attest to the truth of the incident and in support of an insurance claim to repair the damage.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    138 views1 page

    Affidavit of Accident

    Uploaded by

    franceslim24
    Frances Dyan T. Lim files an affidavit of accident regarding damage to her 2017 Ford Ecosport vehicle. On August 6, 2017 while driving on the South Luzon Expressway with her companion Jan Michael O. Borja, a sharp stone hit the windshield, causing a bulls-eye crack. At the time of the incident, Borja was driving the vehicle with Lim's authorization as a licensed driver. Lim executes this affidavit to attest to the truth of the incident and in support of an insurance claim to repair the damage.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    of 1

    Republic of the Philippines)

    Province of Quezon )S.S.


    City of Lucena )

    AFFIDAVIT OF ACCIDENT

    I, FRANCES DYAN T. LIM, of legal age, single, and a resident of 27 Jasmin St.
    Gloria III Subdivision, Brgy. Culiat, Tandang Sora, Quezon City, Philippines, after being
    sworn to in accordance with law, depose and state:

    1. That I am the duly registered owner of a motor vehicle more particularly


    described as follows:

    Make: Ford
    Series: Ecosport 5DR TR
    Year Model: 2017
    Engine No: UEJAHM82341
    Chassis No: MPBSXXMXKSHM82341
    Certificate of Registration No.: 284582406 dated 08/01/2017
    Official Receipt No.: 1218564115 dated 08/01/2017

    2. That on 06 August 2017 (Sunday), at around 4:00pm, I was in the


    passenger seat of my motor vehicle as it was being driven by my companion, JAN
    MICHAEL O. BORJA, through the length of the South Luzon Expressway (SLEX) bound
    from Quezon City to Tayabas City, Quezon, when a sharp stone suddenly and
    accidentally hit the windshield of the aforementioned vehicle with ample force and as a
    result sustained a bulls-eye crack in the windshield;

    3. That at the time of the incident, I authorized my companion, JAN


    MICHAEL O. BORJA, a resident of B6 L2 Carmen Homes, San Pedro, Laguna, to drive
    the vehicle and he is a duly licensed driver with Drivers License No. N2602009081,
    which is valid until 02 May 2022.

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

    IN WITNESS WHEREOF, I have hereunto set my hand this ________________,


    in the City of Lucena, Quezon, Philippines.

    _____________________
    Frances Dyan T. Lim

    SUBSCRIBED AND SWORN to before me, this _____________, 2017 in the


    City of Lucena, Quezon, Philippines, by Frances Dyan T. Lim, who exhibited to me her
    Integrated Bar of the Philippines (IBP) I.D. with Roll of Attorneys No. 63546.

    Doc. No.:______;
    Page No:______;
    Book No:______;
    Series of 2017.

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