B. DETAILS OF INCIDENT

D. BANK ACCOUNT DETAILS INTO WHICH POLICY BENEFIT WILL BE PAID

E. DECLARATION BY CLAIMANT

I, the undersigned declare that the information I have given above is true and correct. I realise that any information found to be false herein will invalidate my claim. I consent to Monarch Insurance Company and any other person/s and/or service providers appointed by Monarch Insurance seeking information about this claim from any source it considers appropriate, and I authorise the providing of such information.

Should any benefits be payable to me, I authorise Lewis Stores (Pty) Ltd to pay the benefits into the above account and release Lewis Stores and Monarch Insurance from any responsibility and / or further claims from this policy, if payment is made into an incorrect bank account that I gave.

I further acknowledge and understand that the full and final settlement paid into the above account will only be finalised after I have returned a signed and completed claim release form.

F. IF AN EVENT OCCURS THAT MAY RESULT IN A CLAIM YOU MUST PROVIDE US WITH THE FOLLOWING DOCUMENTATION:

• The signed and completed claim form must be submitted to Us together with:
  • Obtain the full name, address, and information of any other parties involved, including possible witnesses,
  • In an event where a crime was committed a criminal case must be opened, for example, malicious damage.
  • Certified affidavit detailing the circumstances of the loss or damage,
  • Any other documentation We think is necessary to assess Your claim, such as:
    • Police documents,
    • Quotations, invoices and/or receipts
    • Witness statements
• Proof of ownership and value, if requested by Us
• Loss or damage inspection report,
• In the event of fire damage, a fire report.
• Particulars of any other policy covering the event,
• A clear, certified copy of the Policyholder’s ID, and
• Proof of your bank account or the account of the nominated First Loss Payee into which the claim will be paid which could include one of the following:
  • Bank Statements stamped by the bank, or
  • An Account Confirmation Letter from the bank.
  Please note that the Statement / Letter must not be older than 3 months from the date when the claim is submitted.

Should we require additional information from you in order to complete the assessment of your claim we will communicate this to you with an SMS and/or email and/or telephone call.

Always ensure that any change in your details is immediately communicated to your Claims Assessor (e.g.: Change in your residential address or the contact information of you or the nominated beneficiary indicated in the claim).

WHAT TO EXPECT:

• We will send you a notification with your claim reference number once we have received your claim.
• Once we have confirmed that we have all the necessary information we will start with the assessment.
• We will send you progress updates on the assessment of your claim as well as the outcome of the assessment.
• Failure to observe the above requirements may result in delayed claims assessment or the rejection of the claim.
• Approved claims will be paid into the verified bank account of the Beneficiary or the deceased estate (if applicable).

G. LIST OF DAMAGES / LOSS

IMPORTANT:
Please submit all invoices/receipts for repairs paid, or quotations obtained with the completed claim form.