Production - GLOVO - Courier Accident (Non-European)

Courier Accident
Please note the following before filing your claim
- This insurance covers you for accidents that occured when you are connected with Glovo and up to one hour after you logged-out of the application
- This insurance does not cover the damages to your possessions, for example your bicycle or your phone are not covered by this insurance.
- You will be requested to upload pictures of the accident and to upload any document that will help us to process your claim (e.g. medical certificate, receipts from the hostpital, police report ...) .
- If you have an insurance for your vehicle and your vehicle was damaged, do not forget to let your insurance company know about the accident.
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Form
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Identification and bank account details
Please upload a picture of your ID or passport.*

recto / verso
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Does this Glovo account belong to you, or is it in the name of a third party that legally subcontracted you?*
glovoRiderType*
What is your bank account number?*
In case of eligible claim, we might need it for reimbursement.
Please upload a proof that you own the above mentioned bank account.*

Proof can be : print screen of your bank app, a written statement issued from the bank,... This proof must link bank account number with your name.
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Accident information
When did the accident take place?*

DayMonthYear
Date
Hour Minutes
City of the accident location*
Street and number of the accident location
Vehicle you used at time of incident*
riderVehicleType
Was a third party involved in the accident?*
Do you want to claim medical costs?*
Do you want to claim work incapacity?*
Do you want to claim for broken bones, strains, dislocations or suture (more than 5 stitches) ?*
Describe the accident*
Provide a detailed description of the accident
Please describe your injuries as a result of this accident
Please upload a screenshot from your Glovo app of the last order you had at the time of accident (or just before)*

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Needed Document 1
Needed Document 2
Needed Document 3
Documents for Medical Bills 1
Documents for Medical Bills 2
Documents for Incapacity
Documents for broken bones, strains and dislocations.

Required documents
Please upload medical documents*

All medical documents describing the bodily injuries and the prescribed treatment, such as: first medical assistance report, any additional medical reports
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Please upload all receipts or bills for medical costs with proof of payment

All documents for medical costs that you paid after the accident (hospital care, medication, physiotherapy) with the related proof of payment and medical prescriptions.
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Please upload the medical certificate of temporary disability (the initial or extended medical leave, or the discharge report)

Please upload the document provided by your doctor indicating your incapacity to work for more than 7 days.
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Please upload here any other important documents linked to the accident that you haven’t submitted yet

Any additional document(s) describing the accident such as : police report, accident report, witness report,...
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Remember: Your claim will only be evaluated upon receipt of all necessary documents. If you don't have one of the documents right now, you can still submit your claim and provide additional documentation by email later.
I acknowledge that my claim will be assessed only upon receipt of all necessary documents.

I understand.

Data Protection, Fraud Prevention and Detection & Medical information
In order to administer your claim, this information will be used by the claim adjuster and the insurer and their subcontractors. It may be held on computer and or in manual files for administration and risk assessment purposes.By returning this form, you consent to our processing of your sensitive personal data for the above purposes. Where you have provided information about another person, you confirm that they have appointed you to act for them, to consent to the processing of their personal data, including sensitive data, to the transfer of their information abroad and to receive on their behalf any data protection notices.*

I agree with the Privacy Terms
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Courier Accident