Affidavit Incident Report

Republic of the Philippines ) City of San Pedro ) Laguna )s.s.

AFFIDAVIT OF INCIDENT

I, Elizabeth A. San Juan, of legal age, Filipino, married, and residence of Lot 54 Block 20, Fortuna, San Pedro, Laguna, after being sworn in accordance with the law, hereby depose and state that: 1. I am a Unit Manager of Coco Life (Philippines), Inc.; 2. I am the lawful owner of a motor vehicle, more particularly describe as follows: Make : Toyota Type : SUV Model : 2017 Fortuner V, 4X2, A/T, Attitude black Engine Number : 2343433555094115 Conduction Sticker Number: AGA3432 MV File No.: 1301-0ASDFASDF904 Plate Number: not yet issued

3. On 8 November 2018 (Monday), at around 3:25 in the afternoon after having a meeting with my client about insurance policy at Sun Life Center, while approaching C-5 Road going back to our home at Sta. Rosa, Laguna, approximately 300 meters before the C-5 toll gate entry point, I was shocked when a hard object, seems stone, stroked in my wind shield; 4. I immediately hazard my motor vehicle, and stopped right after the C-5 toll gate to check on my wind shield; 5. Upon checking, I noticed there was cracked in my wind shield brought about by said hard object;

6. That I am executing this affidavit to attest to the truth of the foregoing statements and for any legal purpose it may serve.

Elizabeth A. San Juan AFFIANT Subscribed and sworn to before me this 23rd day of November 2018 at City of Sta. Rosa, Laguna, Affiant exhibited to me her Driver’s License Number

____________, issued ______________________________, _________________.

Doc. No. : ________ Page No.: ________ Book No.: ________ Series of ________

on with

______________at expiration period of