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Affidavit for Car Insurance Claim

Nat Julian S. Beliza files an affidavit of insurance to claim damage to his 2016 Suzuki Swift hatchback. On June 23, 2016, while parking at Embarcadero Legazpi, he accidentally bumped into a protruding canal cover, deforming and tearing the side skirt panel. He executes the affidavit to attest to the truth of the statement for purposes of an insurance claim.

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468 views1 page

Affidavit for Car Insurance Claim

Nat Julian S. Beliza files an affidavit of insurance to claim damage to his 2016 Suzuki Swift hatchback. On June 23, 2016, while parking at Embarcadero Legazpi, he accidentally bumped into a protruding canal cover, deforming and tearing the side skirt panel. He executes the affidavit to attest to the truth of the statement for purposes of an insurance claim.

Uploaded by

czabina fatima delica
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines]

City of Legazpi ] s.s.


x-----------------------------------------x

AFFIDAVIT OF INSURANCE
I, NAT JULIAN S. BELZA of legal age, Filipino, married, a resident of #34 Blk. 40, Imperial
Rosmont Heights, Brgy. 55 Estanza Legazpi City, after having been duly sworn to in accordance
with law, do hereby depose and states that:

1. That I am the duly registered owner of Suzuki Swift with Temporary Plate No. ACR
4796 which is more particularly described as follows:

Make: Suzuki Engine No.: K12MN1765844


Series: Swift 1.2 MT Chassis No.: MA3ZC62S4HAA86581
Body Type: HATCHBACK Plate No.: ACR 4796
Year Model: 2016 MV File No.: 0501-00000048929

2. That on June 23, 2016, at around 9:00 oclock in the evening, while I was parking at
the parking lot of Embarcadero Legazpi I accidentally bump into a protruded canal
cover which causes deformity and tearing on the side skirt panel of the said car.
3. That I am executing this Affidavit to attest to the truth of the foregoing statement
and in purposes of insurance claim.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of June 2017 at
Legazpi City, Philippines.

NAT JULIAN S. BELIZA


Affiant
UMID No. CRN-0111-5828488-7

SUBSCRIBED AND SWORN to before me this 29th day of June 2017 at Legazpi City,
Philippines, affiant exhibited himself to me his Unified Multi-Purpose Identification Card
bearing his photograph and genuine signature as competent proof of his identity pursuant to
the 2004 Rules on Notarial Practice.

Doc. No. ___;


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

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