Please indicate your relation in connection to this claim.
Shopper
Shopper’s insurance carrier
Shopper’s attorney
Third party
Third party’s insurance carrier
Third party’s attorney
Your Information
First name
Last name
Email address
Phone number
Law firm (if applicable)
Insurance company (if applicable)
Shopper’s Information
First name
Last name
Email address
Phone number
Accident Information
Date of accident
Time of accident
Address
City
State
Zip code
Description of accident
When did the accident happen?
While shopper was on the way to the customer’s home
While shopper was on the way to the retailer/grocery store
While shopper was online waiting for a delivery opportunity
While shopper was offline
What is the name of the retailer/grocery store the shopper was picking up or delivering from when the accident happened?
Did a third party sustain any injuries in connection with the accident? A third party is someone other than the shopper.
Yes
No
Unknown
Name of injured third party
Description of injuries
Is this a fatality?
Yes
No
Unknown
Was there any property damage in connection with the accident?
Yes
No
Unknown
Shopper Insurance Policy and Auto Information
Insurer
Insurance policy number
Have you reported this incident to your personal auto insurer?
Yes
No
N/A
Claim number, if reported to insurer
Date reported to insurer
Make
Model
Year
License plate number
State
Third Party Insurance Policy and Auto Information
Insurer
Insurance policy number
Have you reported this incident to your personal auto insurer?
Yes
No
N/A
Claim number, if reported to insurer
Date reported to insurer
Make
Model
Year
License plate number
State
Please provide the email where we can send you confirmation of your claim.
Please attach documentation relating to this accident (i.e. police report, photos, etc.)
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