DSP Insurance Claim Form

Your personal information

Please provide us the following details
Driver's name

First NameLast Name
Driver's date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDriver's birthdate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact email of the DSP
example@example.com
Contact phone of the DSP

Policyholder details
Policy reference
The reference mentioned on your vehicle's insurance certificate or 'green card'.
Company's name
Your Amazon DSP company
Vehicle registration plate number
Vehicle registration plate number

Accident information

Please provide us with the following
When did the accident take place?

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour Minutes
City of the accident location
City of the accident location
Street and number of the accident location
Street and number of the accident location
Short explanation of the incident
Short explanation of the incident
A third party holds you liable (another person asks you for compensation)
Third Party Involved
Was the incident reported to the police?
Please provide the police reference
Was the driver under the influence of drugs, medicines, or alcohol?

Documents
Please upload the European Accident Form

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Please upload pictures of damages

Several photos of the damage will allow our repairers to establish a correct estimate.
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Please upload the repair estimate

Copy of the repair estimate issued by the repair shop you selected.
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Please upload the police report

All medical documents describing the bodily injuries such as : medical report, medical expenses,...
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Please upload any other relevant documents

All documents describing the accident such as : police report, accident report, witness report,...
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Feel free to add any other relevant information

Data Protection, Fraud Prevention and Detection & Medical information
Please agree with the below:

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.
Please agree with the below:

By returning this form, you consent to our processing of your sensitive personal data for the above purposes. You also consent to our transferring of your information to countries which do not provide the same level of data protection as the EU, if necessary for the above purposes. If we do make such a transfer we will, if appropriate, put a contract in place to ensure your information is protected. 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.
Should be Empty:

DSP Insurance claim form