Deliveroo claim for third parties

Deliveroo claim for third parties
Please note the following before filing your claim
- This claim form is for third parties only. If you are a Deliveroo rider, please browse this page to submit your claim in the right form : https://deliveroo.qover.com/
Select the country of the accident*
If you are not a Deliveroo Rider but you were involved in an accident with a Deliveroo Rider in France, please contact SATEC via this link or call this number +33 1 42 80 15 03
Insurer
ref_country
do_not_send_report
claim_language
claimhandler (not used)
TPA Id
fromEmail
replyTo
example@example.com

Your information
Was a third party involved in the accident?*
ThirdParty EntityType
Firstname*
Lastname*
Street*
Street number*
Postal code*
City*
Email*
Phone number*
Country

Deliveroo Rider information
claimant_firstName
Firstname
claimant_lastName
Lastname
Birthday

DayMonthYear
Date
claimant_birthdate

DayMonthYear
Date
claimant_email
example@example.com
Email
example@example.com
claimant_phone
Phone Number
Deliveroo rider account number
Vehicle used by the Deliveroo rider at time of incident*
Physical description of the rider
If the identity of the rider is unknown, provide as much details as possible on the physical description of the rider
claimant_address_country
claimantEntityType
deliveroo_id
claim_type
claim_subtype
accountholding_type

Incident information
When did the incident take place?*

DayMonthYear
Date
Hour Minutes
incident_date

DayMonthYear
Date
Hour Minutes
Street of the incident*
Street number of the incident*
Postal code of the incident*
City of the incident*
Country of the incident*
Describe the incident*
Provide a detailed description of the incident
Describe your damage and/or injury*
Upload any relevant file regarding the third party (optional) (=you)

Cancelof
Are there any witnesses ?*
witness_entity_type
Witness's firstname*
Witness's lastname*
Witness's street
Witness's street number
Witness's postal code
Witness's city
Witness's phone
Witness's email
Witness's country

Data Protection, Fraud Prevention and Detection & Medical information

In order to administer your claim, this information will be used by Qover, the claim adjuster and the insurer. It may be held on computer and or in manual files for administration and risk assessment purposes.
Your personal data will be collected and processed by Qover SA (hereinafter ‘Qover’) that is independent controller responsible for the processing of the personal data you are required to share when you submit your claim. The data will be processed only for the purpose of the use of the services provided by Qover, including risk assessment, insurance contract management, claims and complaints handling and crime prevention (such as fraud) as well as to allow Qover to fulfil its legal obligations. Qover may disclose personal data to the Risk Carrier, namely Zurich and third parties, such as service providers, subcontractors, or to our partners such as Deliveroo and Sedgwick, for the same purposes. Personal data may be transferred abroad, including to countries outside the European Economic Area and/or the UK. Such transfers are subject to appropriate safeguards, including contractual safeguards, in accordance with applicable European regulations and/or the UK ones. The persons concerned have certain rights relating to their personal data and in particular the rights of access, rectification, erasure or restriction of processing or to object to processing as well as the right to data portability. To exercise these rights, you may contact us at any time by writing Qover’s DPO at privacy@qover.com.

For further information about how Qover processes your data please visit our Privacy Policy - EN.

More information about how Zurich processes your personal data and the rights you have as a data subject, please consult the policy documentation
I hereby declare that:*

I provide my explicit consent to the processing of the personal data, including special categories of personal data, I submitted in this claim form.I have read and agree to the information provided and Qover Privacy Policy.I have answered the questions to the best of my knowledge, accurately, and truthfully and have not concealed any information related to this claim. I am aware of the stipulation that any right to benefit may lapse with an untrue statement.
Should be Empty:

Deliveroo claim for third parties

Your information

Deliveroo Rider information

Incident information

Data Protection, Fraud Prevention and Detection & Medical information