Deliveroo UK - Personal Accident claim form

To ensure that our claims team can efficiently handle your claim, please ensure you have the following information ready as you will need this to complete the form:

1. Details of the accident/bodily injury (including location, date and time if possible)
2. Details of the GP or other doctors you were examined by
3. Statement of Fitness for Work (sometimes called a Medical Statement, or Doctor’s Note)
4. Bank details for payment by transfer (cheque option also available)
5. Screenshots of Deliveroo earnings 6 months prior to accident/bodily injury

You can save and return to this form at any time if you need to gather more information.

If you have any questions or queries, please contact our Claims team on:

• Telephone: 0345 841 0056
• Email: cust.servuk@chubb.com.

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 on the next page, or use the online map to search.

If you already know the incident address, you can enter this on the next page.

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 C – Statement of Fitness for Work

To evidence your claim, please provide a copy of your Statement of Fitness for Work (sometimes called a Medical Statement, or Doctor's Note). This should be issued by your GP or hospital doctor. 

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 (CEG) is a Societas Europaea, a public company registered in accordance with the corporate law of the European Union. Members’ liability is limited. CEG is headquartered in France and governed by the provisions of the French insurance code. Risks falling within the European Economic Area are underwritten by CEG, which is authorised and regulated by the French Prudential Supervision and Resolution Authority (4 Place de Budapest, CS 92459, 75436 Paris Cedex 09, France). Registered company number: 450 327 374 RCS Nanterre. Registered office: La Tour Carpe Diem, 31 Place des Corolles, Esplanade Nord, 92400 Courbevoie, France. Fully paid share capital of €896,176,662.

CEG’s UK branch is registered in England & Wales. UK Establishment address: 100 Leadenhall Street, London EC3A 3BP. Authorised by the Prudential Regulation Authority. Subject to regulation by the Financial Conduct Authority and limited regulation by the Prudential Regulation Authority. Details about the extent of our regulation by the Prudential Regulation Authority are available from us on request. Details about our authorisation can be found on the Financial Conduct Authority website (FS Register number 820988).

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.