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Uber Claim Form
Claim Details
Date of Incident
Location of Loss
Description of Loss
/
Driver
Passenger
Driver Details
Passenger Details
Full Name
Mobile Number
Email
Attachment
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Time of Accident
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00:00-00:15
00:15-00:30
00:30-00:45
00:45-01:00
01:00-01:15
01:15-01:30
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Uber Trip Status
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Offline
En Route to Pick Up Passenger
During an Uber Trip or Whilst Transporting a Passenger
I / We declare that all the particulars given above are to the best of my knowledge true and correct.
I hereby consent to and authorize the medical practitioner involved in the patient’s care to discuss treatment details and discharge arrangements with and to AXA Insurance. I agree that a copy this consent shall have the validity of the original.
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