Protection Insurance Claim - Monarch Insurance

Insurance Claim Form

Customer Protection Cover:

Please complete the relevant sections relating to your claim

Lewis Stores (Pty) Ltd is registered as a Financial Service Provider. FSP No 2815

Completed claim forms can be emailed to Lewis Stores head office: claimsdepartment@lewisgroup.co.za or lodged at your nearest branch

Branch Name

Branch Number

Account Number

Customer Name

Cell Number

Sub Account Number

Customer ID Number

Customer Email

A. DEATH / DISABILITY

DEATH

Date of Death

Cause of Death

PERMANENT DISABILITY/TEMPORARY DISABILITY

Date of Disability

Cause of Disability

Standard Cover

Top Up Cover

B. DAMAGE / LOSS / THEFT OF GOODS

Date of Loss

Cause of Damage/Loss/Theft

Address of Loss

Explain how Loss occurred

Police station where loss was reported

Name of investigating Officer

Case Number

Have the police apprehended suspects or recovered any of the stolen goods?

Previously suffered a Loss/Damage?

If yes, please provide details?

Goods to be replaced or balance cleared:

Replacement

Settle Account

Customers with optional top-up goods cover who have chosen to have their goods replaced – Note that if we are unable to contact you in order to arrange the delivery of the replacement goods within 30 (thirty) days of such goods being available for delivery, that we will, instead of replacing your goods, settle the balance on your account (or pay the value proportional to the item/s claimed for where multiple goods are insured in terms of your policy). In such an event, we will send you notification of our inability to make contact with you and our election, and you will have 90 (ninety) days from such notification to contact us to request the delivery of replacement goods, in which event we will reverse the balance settlement and deliver the replacement goods

Description of replacement stock or repairs effected:

SKU Number

Selling Price

SKU Number

Selling Price

SKU Number

Selling Price

SKU Number

Selling Price

SKU Number

Selling Price

C. LOSS OF INCOME / EMPLOYMENT

Date of Loss of Income/Employment

Reason for Loss

Were you aware of the possibility of being retrenched or made redundant, or that your fixed term contract was due to expire at the commencement date of the agreement?

Standard Cover

Top Up Cover

D. DECLARATION OF CUSTOMER/NEXT OF KIN

Name and Surname

Date

Residing at

do hereby declare that the information contained in this claim form is true and correct to the best of my knowledge and belief. I realise that any information found to be false herein may invalidate my claim. I expressly consent to Lewis Stores (Pty) Ltd requesting and receiving personal information related to me/the insured, which personal information is, in the opinion of Lewis Stores (Pty) Ltd, necessary to assess my insurance claim. I hereby irrevocably indemnify any person which provides Lewis Stores (Pty) Ltd with my/the insured’s personal information in terms of my aforesaid consent.

Name Of Claimant

Name Of Branch Manager

Next of Kin Cell Number

Next of Kin Email

By entering your name and date above, you are providing an electronic signature, indicating your agreement with the contents of this form.

E. REMEMBER TO ATTACH THE REQUIRED DOCUMENTS TO YOUR COMPLETED CLAIM FORM

In the event of Damage or Theft or Loss to the Goods:
- Certified affidavit listing the goods and detailing the circumstances of the Damage, Theft or Loss.
- Branch Manager (PC) inspection report for Damage or Theft or Loss claims.
- In the event of a fire claim we may request a fire report.
- Police Incident report for Theft or Loss claims only.
In the event of Death:
- Certified copy of Death Certificate.
- Where death was caused by injury or illness, we may request proof from the deceased’s doctor of the date on which the injury was sustained, or the period of the illness
- Certified copy of Customer ID stamped ‘DECEASED’ if requested.
- Certified copy of Next of Kin ID if requested.
In the event of Disability:
- Comprehensive medical report stating nature and permanence of Disability.
- Proof from your doctor of the date on which you sustained the Injury or duration of the Illness, where Disability was caused by Injury or Illness.
- Letter from your employer - Only where your employment was terminated as a result of your Disability event.
In the event of Loss of Income / Employment:
- Letter from employer stating the reasons for the loss of Income / Employment.
- Recent bank statements.
- Unemployment Insurance Fund forms (UIF-19 form) if requested.
Any other additional information we may require in order to assess your claim:
- We will assess your claim only once we have received from you the completed claim form and the required supporting documents. 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 (e.g.: marriage certificate, Letter from tribal leader etc.).
- Always ensure that any change in your details is immediately communicated to your Claims Assessor (e.g.: Change in your residential address or your contact information or an alternative contact number).

Oct2023_CPI_RSA