Deliveroo UK - Personal Accident claim form

To ensure that our claims team can efficiently handle your claim, please ensure all relevant questions relating to your claim are completed. To assist in the handling of your claim:

• Please ensure all supporting documentation is provided.
• Please ensure that all relevant questions are answered and that all appropriate sections, boxes and signatures are completed, failure to do so may delay the processing of your claim.

If you have any questions or queries, please telephone Chubb customer services by calling 0345 841 0056 or emailing cust.servuk@chubb.com.

What you will need to complete this form:

1. Details of the incident (including location, dates and times).
2. Details of the GP and doctors you were seen by.
3. Statement for fitness for work (a certificate completed by your GP) if you are claiming for loss of income.
4. Bank details for payment, if you prefer transfer over a cheque.
5. Screenshots of your Deliveroo earnings.

Preparing this information will make it easier for you to complete the form, although you can also save this form at any time and return to it later.

Section A - Claim details

Please complete this section to provide your personal details, and information about your claim.

Where did the incident take place?

Don't know where you are or exactly where the incident happened?

If you're at the incident location now, click this link and drop the 3 words into the street address line in the next step, or use the online map to search.

If you already know the incident address, you can enter this by clicking NEXT.

Section B – Access to Medical Reports Act 1988
 
Before your doctor can give a medical report on this claim form which is a requirement of this claim, you must give your consent. Before giving your consent, you should be aware of your rights under the act which are summarised as follows:

1. You may withhold your consent.
2. You may see the report before it is sent to us within 21 days from the date of this report.
3. You may ask to see the report for up to six months after the report is completed.
4. You may ask the Doctor to amend any part of the report which you consider to be incorrect or misleading. If the Doctor does not agree with your request you may attach your comments to the report.

Note: The Doctor may withhold all or part of the report from you if they consider that you may be physically or mentally harmed by it.

Section D – Payment Details

In the event that your claim is accepted, you will be paid directly. To be able to process these payments you will need to provide us with your payment details.

Section E – General Data Protection Regulation (GDPR)

Chubb use personal information which you supply to us for underwriting, policy administration, claims management and other insurance purposes, as further described in our Master Privacy Policy, available here or by searching ‘Master Privacy Policy’ on www.chubb.com. You can ask us for a paper copy of the Privacy Policy at any time, by contacting us at dataprotectionoffice.europe@chubb.com.

Chubb European Group SE is an undertaking governed by the provisions of the French insurance code with registration number 450 327 374 RCS Nanterre and the following registered office: La Tour Carpe Diem, 31 Place des Corolles, Esplanade Nord, 92400 Courbevoie, France. Chubb European Group SE has fully paid share capital of €896,176,662 and is supervised by the Autorité de contrôle prudentiel et de résolution (ACPR) 4, Place de Budapest, CS 92459, 75436 PARIS CEDEX 09. UK business address: 100 Leadenhall Street, London EC3A 3BP. Supervised by the Autorité de contrôle prudentiel et de résolution (ACPR) 4, Place de Budapest, CS 92459, 75436 PARIS CEDEX 09 and subject to limited regulation by the Financial Conduct Authority.

Details about the extent of our regulation by the Financial Conduct Authority are available from us on request. You can find details about the firm by searching ‘Chubb European Group SE’ online here.

Section F – Declaration

Before submitting your claim, please check the details and add your signature on the next section. You will then get the chance to add any more supporting information, before submitting your claim.