Rewire Claim Form

Claim Form
✅ The Rewire users registered in those countries can submit a claim :

Belgium, Germany, Estonia, Spain, Finland, France, Greece, Ireland, Italy, Lithuania, Luxembourg, Latvia, Malta, Netherlands, Poland, Portugal, Slovenia, Slovakia

❌ The Rewire users registered in United-Kingdom, Cyprus or Austria are not eligible to the insurance program and therefore are not allowed to submit a claim

Choose which claim you want to report *
claim_type
claim_subtype
claim_language
Country
ref_country
Are you the insured person ? *
claimant_egals_insured
Those data are present to orient properly the emails from jotform
claims@qover.com
example@example.com
aiginsu@rewire.to
example@example.com
Qover Customer Care

Personal information of the insured

The insured is the ReWire customer whose interest is protected by the insurance
Name *

First Name Middle Name Last Name
Date of birth *

Day Month Year
Date
Phone number *
Email *
example@example.com
Street *
Street number *
Zip code *
City *
Country of residence *
insured_country
Rewire IBAN number *
2 letters followed by 18 digits
insured_entityType

Personal information of the claimant

The claimant is the person who is acting on behalf of the insured
Name *

First Name Middle Name Last Name
Date of birth *

Day Month Year
Date
Phone number *
Email *
example@example.com
Street *
Street number *
Zip code *
City *
Country *
claimant_entityType

Accident information
Date and time of the accident *

Day Month Year
Date
Hour Minutes
Address of the accident
Describe the location of the accident *
Explain the most accurate location : i.e at home, in a building, on the street, in a transport, ...
City *
Country *
Description of the accident *
explain in details what happened just before and during the accident

Medical information
Describe the injuries resulting of the accident *
Has the insured been confined to a hospital ? *
hospi
From *

Day Month Year
Date
To *

Day Month Year
Date
treatments_ongoing
Is the insured still receiving medical treatments of examinations ? *
Name of the doctors and their specialties *
What is the expected duration of the treatment ? *
Death date *

Day Month Year
Date
Death location

Please provide the place where the insured deceased
Describe the death's location *
Explain the most accurate location : i.e at home, in a building, on the street, in a transport, in the ambulance, at hospital ...
City *
Country *
Please choose the option you prefer *
Choose repatriation if the burial or cremation takes place in the country of origin of the insured. Choose funeral if the burial or cremation takes place in the country of residence of the insured.

Occupational information
What is the occupation of the insured ? *
What is the occupation status of the insured ? *
Is the insured unable to work due to the injury resulting from the accident ? *
workincapacity
Inability to work - from *

Day Month Year
Date
Inability to work - to *

Day Month Year
Date
When is the insured expecting to work again ? *

Day Month Year
Date
Explain why the insured is currently unable to work *

Evidences and attachments
All documents describing the accident

such as police report, accident report, witness report,...
Cancel of
Medical report *

Cancel of
Medical certificate of temporary total incapacity

Cancel of
Death certificate *

Cancel of
If the burial has already been done in the insureds country of residence, upload the burial cost expenses

Cancel of

Declaration
I hereby declare that I have answered the questions to the best of my knowledge, accurate, in accordance with the truth and not to have concealed any information relating to this claim; I am aware of the stipulation that any right to benefit may lapse with an untrue statement; I have knowledge of the contents of this form. *
Personal data
Your personal data (hereinafter the ‘data’) will be collected and processed by AIG Europe, Netherlands, located at the address above (hereinafter ‘AIG’) in accordance with the Code of Conduct for the processing of personal data by financial institutions (‘Code of Conduct’). AIG is the controller responsible for the processing of the personal data you are required to share to benefit from the AIG insurance product. The data will be processed only for the purpose of the use of the services provided by AIG, including risk assessment, insurance contract management, claims handling and crime prevention (such as fraud) as well as to allow AIG to fulfill its legal obligations. In connection with AIG’s activities and for the purpose of good service, AIG may transfer these data to other companies of the group of companies it belongs to, to subcontractors, insurance intermediaries such as Qover and Rewire or to partners. These companies, subcontractors or partners may be located in countries outside the European Economic Area that do not necessarily offer the same level of protection as The Netherlands. With regard to these transfers, AIG will take precautionary measures to ensure the protection of data in these countries as well as possible. You allow Rewire, AIG and its processor Qover to share and process your personal data including your ReWire IBAN number among each other for the above purposes. According to the Code of Conduct, you are entitled to access, amend or oppose (for a reasonable cause) to the processing of data related to you. To exercise these rights, you can contact AIG at any time in writing at functionarisvoordatabescherming.nl@aig.com. For further information on the mechanisms for processing your data by AIG, you will find AIG’s complete Global Privacy policy on http://www.aig.com/nl-privacybeleid
CIS Foundation
In order to ensure a responsible acceptance, risk and fraud policy we may check your (personal) data and have it recorded in the CIS Foundation, Bordewijklaan 2, 2591 XR The Hague, PO Box 124, 3700 AC Zeist. The purpose of processing personal data in CIS is to detect the abuse of financial products and services of insurers, preventing, combating and controlling risks to the fullest extent. For more information, see www.stichtingcis.nl.
I consent with the use of my personal data to handle this claim *
Should be Empty:

Claim Form

Those data are present to orient properly the emails from jotform

Personal information of the insured

Personal information of the claimant

Accident information

Address of the accident

Medical information

Death location

Occupational information

Evidences and attachments

Declaration

Personal data

CIS Foundation