Republic of the Philippines)

City of Sta. Rosa, Laguna.. )S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, URIEL JEREMIAH M. APALE, of legal age, Filipino citizen, and a resident of 105
Poinsetta San Jose Village 2 P5, Biňan, Laguna, after having been sworn in accordance with law,
hereby depose and say that:

1. I am a duly licensed driver with Non-Professional Driver’s License No. N26-16-020478,

valid until 04 September 2023, and the authorized/duly permitted driver of a certain
vehicle registered under the name of my father, Mr. Antonio Eduardo C. Apale, more
particularly described as follows:

Make: Hyundai Kona

Engine No.: G4NHJU637912
Chassis No. KMHK381ABKU185625
Body Type: Sedan
Plate No.: DAK2811
MV File No. 0401-00000868-87

2. The subject vehicle is insured by FPG Insurance under Policy Number 226067 valid
from 26 January 2019 until 26 January 2020;

3. In the morning of 19 October 2019, while I was driving the said vehicle on my way to
Colegio de San Juan de Letran, Calamba where I attend school, I just turned left in an
intersection leading to the back gate entrance of my school when I suddenly veered
toward the rightmost part of the road and the car accidentally fell into an uncovered
drainage/canal at the side of the road. The impact of falling into the drainage caused
damages to the under chassis of the motor vehicle requiring repairs and replacement
of parts such as crossmember compl, arm, wheel assy, front axle, tie rod, ball joint, front
stabilizer, cover bumper, bracket assy, roll rod tire, etc.;

4. The said canal was unnoticeable as there was a mound of dirt with grasses before the
pavement blocking immediate view of the hollow area;

5. The accident was unavoidable despite exercise of due diligence in driving the motor
vehicle;

6. There were no traffic enforcers at the time and area of the incident;

7. I am executing this affidavit to attest to the truth of the foregoing in support of my father’s
claim from his insurer for payment/reimbursement of the cost of repair and replacement
of parts on the damaged motor vehicle and such other claims that the insured may be
entitled under the insurance policy, and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 19 October 2019, at Sta. Rosa
City, Laguna, Philippines.

URIEL JEREMIAH M. APALE

Affiant

SUBSCRIBED AND SWORN to before me in Sta. Rosa City, Laguna this 19 October
2019. Affiant exhibited to me his Driver’s License No. N26-16-020478, valid until 04 September
2023.

Doc. No. __80_;

Page No. _17_;
Book No. _I_ ;
Series of 2019.