Affidavit of Death Due to Vehicle Accident for Insurance Claim

Republic of the Philippines)

Province of_________________) S.S.
City/Municipality of_____________)
x-------------x
AFFIDAVIT
I,____________,legal age, widow and a resident of____________, Philippines,
after having been duly sworn to in accordance with law, do hereby depose and
state the following:
That I am the (widow/widower)of____________;
That my (husband/wife) died on_____________because of_____________injuries
sustained in a vehicular accident as per the results of the autopsy conducted by
Dr.____________;
That per investigation of the_____________Police Station, my (husband/wife) died
as a result of a vehicular accident at ____________ when while he
was_____________, he was bumped / hit by a truck coming from the opposite
direction;
That my husband was a duly licensed driver at the time of the incident and was
carrying Driver's License No.____________and was riding on
a_____________,_____________in color and with Plate No._____________owned
by _____________with Certificate of Registration No._____________;
That I am executing this affidavit to attest to the truth of the foregoing and for
whatever legal purposes that this statement may serve.
IN WITNESS WHEREOF, I have hereunto set my hands this_____________, in the
City of_____________, Philippines.
AFFIANT

(JURAT)