Republic of the Philippines ]

Naga City
] s.s.
x-------------------------------------------x
AFFIDAVIT
I, RACHEL ELIZABETH ZANE, of legal age, Filipino, single, with
residence address at Ibalong Village, Taysan, Legazpi City, after having
been sworn to in accordance with law, hereby depose and state:
1. That I am District Sales Manager of XYZ, Inc, assigned in Bicol
Region.
2. That a Toyota Wigo MT 1.0 2016 with plate number ABC 1234 is
registered in the name of the above-mentioned company under
Certificate of Registration No. 123456789.
3. That around 8:20 in the morning of September 13, 2016, while I
was at Guinobatan, Albay driving the said car going to Naga City,
I saw a girl on the left side of the road with a small rock in her
hand. The next thing I knew, the same girl threw the rock directly
at the car. Since the girl seemed to be out of her mind, I
continued driving until I stopped in Ligao City to check for
possible damage of the car. Initially, I was not able to see any
scratches or visible damage on the car.
4. I immediately informed Mr. Harvey Reginald Specter, the
Regional Sales Manager and my supervisor about the incident. I
was advised to have the car washed to vividly check the possible
car damages.
5. Since I have been busy, I was only able to have the car washed
over the weekend. I was later informed by the car wash boy that
the car has sustained damages located between the drivers
window and the wind shield.
6. That upon estimate by Pearson Specter Litt Corp. located at
Cabangan, Legazpi City, the repair and replacement of the
damages part of the said vehicle is estimated at P 123,456.00;
7. That I am executing this affidavit to attest to the truthfulness of
the foregoing statements and for purposes of insurance claim.
IN WITNESS WHEREOF, I have hereunto set my hand this
October 5, 2016 at Naga City, Philippines.

RACHEL
ELIZABETH ZANE
Affiant
SUBSCRIBED AND SWORN to before me this October 5, 2016 at
Naga City, Philippines. Affiant exhibited to me her Professional Drivers
License with number E01-34-5678910 bearing her photograph and
genuine signature as competent proof of her identity pursuant to the
2004 Rules on Notarial Practice.
Doc. No. ____;
Page No. ____;
Book No. ____;

Series of 2016.