B. DETAILS OF ACCIDENT

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

D. 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.

E. IN ADDITION TO THE COMPLETED CLAIM FORM, YOU WILL ALSO NEED TO SUBMIT THE FOLLOWING REQUIRED SUPPORTING DOCUMENTS FOR YOUR CLAIM

• A clear, certified copy of the Policyholder’s and/or Beneficiary’s I.D,
  
  Death as a result from an Accident:
  • A police incident report,
  • A road traffic Accident or other Accident report (if the cause of death / disability was as a result of a motor vehicle accident),
  • A full post-mortem report, and/or
  • A body identification form.
• Proof of bank account 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 of when the claim is submitted.
  The following death reports can be obtained and provided to support your claim:
  • Certified Death Certificate issued by the Dept. of Home Affairs,
  • Certified copy of the Notification of Death (form no. BI/DHA 1663) - completed by an official who is reporting the death,
  • Certified Death Report (form no. BI/DHA-1680) - available from the Dept. of Home Affairs after a death has been reported and registered.
  
  Disability as a result of an Accident:
• A certificate from the Hospital or doctor where you received medical care confirming the following:
  • the nature, extent, and permanence of the Disability,
  • the date and nature of the injury and/or Accident resulting in your Disability; and if applicable,
  • A report indicating that you are unable to live without assistance or a full-time caregiver as a result of the Accident and/or injury,
• If you were employed at the time of the Accident, and your employment was terminated following Disability as a result of the Accident, we will require a letter from your employer confirming the termination of your employment as a result of your Disability, and
• You agree to undergo a medical examination, at a reasonable time and at Our expense, by a medical practitioner appointed by Us, if We request You to do so.

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).