I. Introduction

This Affidavit of Vehicle Damage for Insurance is executed by Lowell Quizon, the vehicle owner, to affirm the damage sustained to the vehicle described below for the purpose of insurance claims with Venturex, the insurance company. This affidavit is notarized by [Your Name], the notary public, to verify the authenticity of the damage claim and facilitate the insurance process.

The vehicle involved in this claim is described as follows:

• Vehicle Make: Ford

• Vehicle Model: Escape

• Vehicle Year: 2050

• Vehicle Identification Number (VIN): 1FMCU9G96LUB87654

• License Plate Number: XYZ9876

• Odometer Reading: 12,000 miles

II. Declaration of Vehicle Damage

I, Lowell Quizon, the owner of the vehicle, hereby declare and affirm the following regarding the damage sustained to the vehicle described above:

• On February 10, 2050, the vehicle was involved in a collision, resulting in significant damage to the front bumper, headlights, and grille. The vehicle was stationary at the time of the accident, and the damage occurred when a third-party vehicle collided with the front of the vehicle.

• The damage has been thoroughly assessed by a certified mechanic, Clint Renner, at Renner Auto Repairs, located in Richmond, VA. The mechanic’s report indicates the following damages:

  • Front bumper dented and cracked

  • Both headlights shattered

  • Grille severely damaged

  • Minor structural damage to the chassis

• The total estimated cost of repairs provided by the mechanic is $5,500.00. The vehicle is currently not in a drivable condition and is awaiting repairs.

• I have submitted the mechanic’s report and photos of the damage to Venturex, and I am requesting assistance through my insurance policy for the repair costs and any further assistance required.

III. Insurance Company Details

This affidavit is submitted to Venturex, the insurance company, for the purpose of processing the damage claim associated with the incident on February 10, 2050. The vehicle is covered under the following policy:

• Insurance Policy Number: 1234567890

• Coverage Type: Comprehensive

• Policy Holder: Lowell Quizon

• Effective Date of Policy: January 1, 2050

The claim has been initiated, and I am seeking reimbursement for the costs associated with the repair of the vehicle and any additional damages that may have occurred.

IV. Notary’s Acknowledgment

I, [Your Name], the notary public, affirm that Lowell Quizon appeared before me on March 4, 2050, and swore to the truth of the information provided in this affidavit. I have verified the identity of the owner and confirmed that this affidavit was signed in my presence.

This affidavit was signed and notarized on March 4, 2050, in the state of Virginia, and I certify that the statements made by Lowell Quizon are made under oath.

Name: [Your Name]
Notary Public
Date: March 4, 2050

V. Conclusion and Signatures

By signing this affidavit, the owner affirms the accuracy of the information provided regarding the vehicle damage and agrees to the insurance claim being processed under the terms of the policy with Venturex.

For Vehicle Owner:

Name: Lowell Quizon
Date: March 4, 2050

This affidavit serves as a formal and binding document for the insurance claim process, providing the necessary information to confirm the vehicle damage and facilitate the reimbursement of repair costs under the insurance policy with Venturex.

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