KGANYAKOLOI

Claim Form

KK

You the policyholder are our most important asset. You have loyally supported Kganya by paying your premiums. You have done this knowing that one day you may have to claim. That day has now arrived and you deserve to be assisted in the most efficient and sympathetic way.

It is our duty as Kganya to make sure that the claims process is as smooth and simple as possible. This Claim form has been created with this in mind.

If you follow the process closely we will be able to guide you through this stressful time.

CAR INSU

RANCE O

NLY

April 2017

Z ION C HRISTIAN C HURCH

We remind you of your rights which are contained in the Statutory Notice in the Kganya Koloi Policy

The underwriters are:

Centriq Insurance Company Limited:Postal Address: P O Box 55674, Northlands, 2116 • Address: 2nd Floor, The Oval West, Wanderers Office Park, 52 Corlett Drive, Illovo

Co. Reg: 1998/007558/06 • FSP Number: 3417 • Website: www.centriq.co.zaTelephone Number: 011 268 6490 • Fax: 011 268 6495 • Email: info@centriq.co.za

The Administrators are:

Kganya Insurance Administrators (Pty) Ltd (RF):Postal Address: P O Box 394, Rivonia, 2128

Address: South Wing, 328 Rivonia Blvd, Rivonia 2128Co. Reg: 95/007875/07 • FSP Number: 7974

Telephone Number: 0800 000 538 • Fax: Fax: 086 519 4753 • Email: claimsps@kganya.co.za

Dear Policyholder,

You are completing this claim document because you have suffered a loss. I have instructed Kganya Insurance Administrators (Pty) Ltd (RF) Ltd to make sure that they are of service to you at all times. Equally, the committees of Zion Christian Church are aware that they must provide you with all the documentation needed to ensure that your claim can be considered.

I wish to advise you that these documents are important and will allow Kganya Insurance Administrators (Pty) Ltd (RF) to be of assistance to you, if they are completed properly. I therefore urge you to take the time to complete these documents with care and to make sure that all the necessary information is placed upon them.

Kganya Insurance Administrators (Pty) Ltd (RF) under my direction has also been instructed by me to deal fairly with you. I have over many years seen to it that products are developed that can be of benefit to you. You however have a duty to deal fairly with both Kganya Insurance Administrators (Pty) Ltd (RF) and Zion Christian Church. I will therefore request that you are always truthful and that you co-operate with them during this process.

His Grace the Bishop Dr BE Lekganyane

His GraceThe Right Reverend Bishop Dr BE Lekganyane

Headquarters: Zion City Moria. P O Box 1, Boyne, 0728

Z ION C HRISTIAN C HURCH

WHICH SECTION SHOULD I COMPLETE?This is a step by step guide which will allow you to give us all the information we require to process your claim. Remember to complete the document in detail.

Section 1:

A, B & C: YOUR DETAILS You must tell us about yourself here.

D: VEHICLE DETAILS These are the details of your vehicle that you have insured and which has been involved in an accident or has broken down as a result of mechanical or electrical failure.

E: INCIDENT DETAILS You will now describe how the incident happened.

F: OTHER VEHICLES IN THE ACCIDENT You must complete this section if you where involved in an accident with another vehicle. It is important for us to know the name and address of the owner of the other vehicle.

G: OTHER PROPERTY It is possible that other property was damaged apart from the vehicles. This could be a house or a wall for example. Tell us who the owner of the other property is and what was damaged.

H: OTHER INSURANCEYou must inform us if your vehicle is also insured at any other insitution. If necessary, we will work in conjunction with them to finalise your claim.

I: PASSENGERS INJURED OR DECEASED Perhaps there were people injured or who passed away in the accident. These persons may have been passengers in your vehicle. We will need to know who these people are so that we can be of further assistance to you. There are three different sections. See which applies to yourself.

J: INJURED PEDESTRIANS OR PERSONS IN THE OTHER VEHICLE Perhaps pedestrians or persons in the other vehicle were injured or killed in the accident. We will need to know who these people are so that we can be of assistance to you.

K: REPORT TO THE SA POLICE No matter how small the accident is you have to report it to the South African Police within 24 hours by law. You will receive either an “AR” number or an “OV” number from them. This stands for Accident report. If the Police have opened a criminal case you will receive a “CR” number or an “MR” number. This stands for a Crime Register report. Make sure you get either one of these numbers.

L: VERIFICATION OF CLAIM We are going to need certain documents to allow us to process your claim quickly. We want you to take some time and trouble with these documents to ensure that they accompany this form. Your claim could be delayed if you do not provide these documents. We also need the church committee to verify some of your information.

Section 2: WHAT MUST YOU DO NOW?

SECTION 1 KGANYA KOLOIIMPORTANT: In all cases the final decision as to whether or not to admit a claim rests with Centriq Insurance Company Limited as Underwriter

C: YOUR ADDRESS DETAILS:

Where do you stay?:

Code:

Where do you receive your post?:

Code:

These are the details of your vehicle that you have insured and which has been involved in an Accident / Breakdown.

D: VEHICLE DETAILS:

Make of vehicle (like Toyota, Mercedes...)

Model of vehicle (like Yaris, E200...)

Registration Number:

Colour:

Engine Number: (Off Licence Disk)

VIN Number: (Off Licence Disk)

Year Model:

You will now describe how the incident happened.

E: INCIDENT DETAILS:

Person driving (full names):

Driver Licence Number:

Date Drivers Licence Issued: D D M M Y Y

How did the incident happen?:

Place where incident occurred:

I HEREBY DECLARE THAT I AM THE INSURED PERSON / CLAIMANT AND I AGREE THAT MY CLAIM BE PAID INTO THE ABOVE ACCOUNT

Name of Bank: ChequeSavingsAccount Type:

Account Number:

Name of Account Holder:

B: BANK ACCOUNT DETAILS:

I, the policyholder / claimant, hereby request that the amount of my claim (if approved) be paid into the following bank account (proof of account details in the form of a recent bank statement to be attached). I understand that the company will not be liable should the payment be made to a third party account.

Branch Name: Branch Code:

You must tell us about yourself here.

A: YOUR DETAILS:

Church Name:

First Names (Full Names):

Surname:

Date of Birth: D D M M Y Y I.D Number:

Tel (Home):

Tel (Cell):

Policy Number:

Church Code:

Email:

Type of incident: Accident Theft Breakdown Windscreen

Date of incident: Time of incident:D D M M Y Y H

SECTION 1 KGANYA KOLOI

F: OTHER VEHICLES IN THE ACCIDENT:

You must complete this section if you where involved in an accident with another vehicle. It is important for us to know the name and address of the owner of the other vehicle.

First names (Full Names):

Surname:

ID Number:

Address:

Code:

Make of vehicle:

Model of vehicle:

Registration Number:

Description of Accident / Breakdown:

Drawing of Accident:

Tel (Work): Tel (Cell):

G: OTHER PROPERTY:

Address:

Code:

It is possible that other property was damaged apart from the vehicles. This could be a house or a wall for example. Tell us who the owner of the other property is and what was damaged.

First Names (Full Names):

Surname:

Property Damaged:

Tel (Work): Tel (Cell):

Are they insured? Name of Insurer if Yes:Yes: No:

SECTION 1 KGANYA KOLOI

I: PASSENGERS INJURED OR DECEASED:

Perhaps there were people injured or who passed away in the accident. These persons may have been passengers in your vehicle. We will need to know who these people are so that we can be of further assistance to you. There are three different sections. See which applies to yourself.

I1: PERMANENT INJURIES:

I2: DEATH OF A PASSENGER:

DETAILS OF DECEASED PASSENGER

IF THE POLICYHOLDER OR A PASSENGER IN THE VEHICLE WAS KILLED A CLAIM WILL BE ALLOWED. WE WILL REQUEST THAT YOU FILL IN THIS PART OF THE DOCUMENT

Name of deceased:

I.D Number: Gender: Male: Female:

This certificate is required to substantiate a claim under case number:

TO BE COMPLETED BY THE INVESTIGATING OFFICER AT THE POLICE STATION WHERE THE CASE WAS REPORTED

DETAILS RELATING TO THE CAUSE OF DEATH OF THE PASSENGER:

Was a blood alcohol test performed on the deceased? Yes: No:

Have criminal proceedings been instituted? Yes: No:

What time was it performed?

What was the charge?

Who was charged?

What was the verdict? (if already finalised)

Investigating officer

Telephone Number:

IF YOU OR A PASSENGER IN YOUR VEHICLE IS PERMANENTLY INJURED YOU WILL BE ALLOWED TO CLAIM. WE WILL REQUEST THAT YOU FILL IN THIS PART OF THE DOCUMENT

Name of person injured:

Address of Injured Person:

Code:

I.D Number:

What is the nature of the injury:

Name and address of hospital where injured person was taken:

H: OTHER INSURANCE:

You must inform us if your vehicle is also insured at any other insitution. If necessary, we will work in conjunction with them to finalise your claim.

Other Insurance: Yes: No:

Name of Insurer if Yes:

Address:

Code:

Name of passenger:

I.D NUmber:

Tel (Cell):

Type of Injury:

Cost of medical expense: (To be supported by accounts paid by yourself for this injury)

SECTION 1 KGANYA KOLOI

I3: PASSENGERS MEDICAL EXPENSES:

J: INJURED PEDESTRIAN OR PERSONS IN THE OTHER VEHICLE:

IF A PASSENGER IN YOUR VEHICLE WAS NOT PERMANENTLY INJURED BUT HAD MEDICAL EXPENSES YOU WILL BE ALLOWED TO CLAIM. WE WILL REQUEST THAT YOU FILL IN THIS PART OF THE DOCUMENT

If you do not have enough space use another claim form and let us have these details

Address:

Code:

Name:

Tel (Cell):

Injury:

Perhaps pedestrians or persons in the other vehicle were injured or killed in the accident. We will need to know who these people are so that we can be of further assistance to you

K: REPORT TO THE SOUTH AFRICAN POLICE SERVICES:

Print Name:

Telephone Number:

SAPS reference number:

Name of Police Station:

Date reported to SAPS:

Telephone number of SAPS station:

No matter how small the accident is you have to report it to the South African Police within 24 hours by law. You will receive either an “AR” number or an “OV” number from them. This stands for Accident report. If the Police have opened a criminal case your will receive a “CR” number or an “MR” number. This stands for Crime Register report. Make sure you get either one of these numbers.

DateSigned atD D M M Y Y Y Y

Signature of Investigating Officer

Police Station stamp

SECTION 1 KGANYA KOLOIL: VERIFICATION OF CLAIM:

CHURCH COMITTEE:

Please insert the last four receipt numbers bought before the date of loss below

It is certified that to the best of our knowledge and belief the information is accurate and the person claiming has paid before the date of accident:

I CONFIRM THAT THE DETAILS IN THIS DOCUMENT ARE TRUTHFUL AND I AM AWARE THAT IF ANY STATEMENT I HAVE MADE IS UNTRUTHFUL THIS CLAIM WILL BE DECLINED AND FURTHER ACTION WILL BE TAKEN AGAINST ME

THESE DOCUMENTS ARE REQUIRED TO FINALISE YOUR CLAIM:

Type: Number: Date Sold: Type: Number: Date Sold:

DateSigned atD D M M Y Y Y Y

Signature of Policyholder/Claimant

Name: Signature: D D M M Y Y

Name: Signature: D D M M Y Y

Name: Signature: D D M M Y Y

Name: Signature: D D M M Y Y

Copy of Policyholder’s ID and Driver’s Licence

Vehicle Registration Certificate

Two Quotations for Repairs

Copy of towing invoice (if applicable)

Photographs of damage

Copy of Driver’s Licence and ID of person driving if not the same as above

Copy of injured Person’s ID

Final Medical Report

Medical Bills Paid

Death Certificate (If Applicable)

Copy of Policy Shedule

Copy of Receipts

Required Included

1. Is the Policy Book up to date? Yes: No:

2. Is the policyholder known to the church committee? Yes: No:

3. Is the injured person known to the church committee? Yes: No:

Bank statement or proof of bank account:

Third Party Claims (to be referred to the offices of Kganya Insurance Administrators (Pty) Ltd (RF))

Third Party Damage:

Quotation for Repair

Proof of Ownership of Damaged Property

SECTION 2 WHAT MUST YOU DO NOW

KK

By Hand (Kganya Service Centre):

Posted: Date: D D M M Y Y Y Y

Received by (Full Name):

Post Office:

THE PERSON SUBMITTING THIS CLAIM MUST RETAIN THIS TEAR OFF AS PROOF OF SUBMISSION OF HIS/HER CLAIM TOKGANYA INSURANCE ADMINISTRATORS (PTY) LTD (RF):

Please phone Kganya Insurance Administrators (Pty) Ltd (RF) and advise them that you have completed this claim form and give them the reference number above. Their contact details are 0800 000 538.

SECTION 1: Kganya Koloi

I HAVE COMPLETED THE FOLLOWING SECTIONS OF THIS CLAIM FORM:

PROOF OF CLAIM SUBMISSION:

Cell Number:

Church No: Church Name:

Name and Surname:

DateKganya Service CentreD D M M Y Y Y Y

Service Centre Manager

Now that you have completed the relevant claim form and included all the documents to finalise your claim you need to do the following:

Complete the proof of submission at the botttom of this page.

Take all the documents to your nearest Kganya Service Centre who will then send it to us for processing. The Service Centre Manager must sign the tear off slip at the bottom of this page;

or you can post or email it to us at the following address:

Kganya Insurance Administrators (Pty) Ltd (RF) P O Box 394 RIVONIA 2128

Email: claimsps@kganya.co.za

Tear off this page and keep it in a safe place.

Once you have done the above please phone us on 011 0800 000 538 during 07:30 and 16:00 weekdays only and advise us of your claim and how you have forwarded this to us.

KGANYA INSURANCE ADMINISTRATORS EMPLOYEES ARE NOT AUTHORISED TO PROVIDE YOU WITH ANY ADVICE. THEY ARE ONLY PERMITTED TO COLLECT THESE DOCUMENTS AND FORWARD THEM TO THE NECESSARY DEPARTMENT.