DRAFT - GLOVO - Sick leave (European)

Declaration of sick leave for the insurance company

Daily allowance in case of incapacity to use the App due to illness
Please note the following before filing your claim
- You can benefit from this coverage if you suffer an ilness and are not able to use the App anymore
- The daily benefit will be paid by the insurance company as from the 8th day of your incapacity and up to a maximum of 30 days
- The insurance company will request original copy of the medical documents and receipts.
- Substitute can not benefit from this insurance
- This insurance only applies to registered Courier App users
You are covered only if you performed at least 30 deliveries throught the App in the last 8 weeks prior to the claim.
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coverage
claim_type
subType
claimLanguage
claimantEntityType
refsCountry
claimhandler

Your personal information

Please provide us the following details
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Email*
example@example.com
Phone Number*
Where do you live ?
Street*
Number*
Box*
Locality
Postcode*
City*
Country*
claimant_address_country*
If your country is not listed in the above dropdown, you can not benefit (yet) from this insurance
brokerName
fromEmail
replyTo
example@example.com

Your ID or passport number
Please upload a picture of your ID or passport.

Cancelof
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. For Europe : IBAN format is requested
Please upload a proof that you own the above mentioned bank account. Please do not upload any credit card information.*

Proof can be : print screen of your bank app, a picture of your banking card, a written statement issued from the bank,... This proof must link bank account number with your name.
Cancelof

Sick Leave
Please select the start date of your incapacity as stated on the medical certificate*

DayMonthYear
Date
Please select the end date of your incapacity as stated on the medical certificate*

DayMonthYear
Date

Evidences
Please upload medical report related to the origin and development of your disability*

Cancelof
Please upload the sick leave certifiate*

Cancelof
Remember: your claim will be assessed only upon receipt of your medical file. If you can't provide one of the above, leave a comment to explain:
I acknowledge that my claim will be assessed only upon receipt of my medical file.*

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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Declaration of sick leave for the insurance company