I, with the above-mentioned particulars and the undersigned, do hereby declare that the information contained in this complaint form is
true and correct to the best of my knowledge and belief. I expressly consent to Monarch Insurance Company Limited (‘MICL’) requesting
and receiving personal information related to me/the insured, which personal information is, in the opinion of MICL, necessary to assess
my insurance complaint and/or claim. I hereby irrevocably indemnify any person which provides MICL with my/the insured’s personal
information in terms of my aforesaid consent.