Fisker Insurance Claim Form

Welcome to Fisker Insurance claim form

We are very sorry you were involved in an accident with your car. Please fill out the form below and we will assist you with your claim.

Please make sure you have the following documents at hand
(you will be required to upload them later on):
- European Accident Form (if available)
- Pictures of damaged car(s)
refsCountry
claim_type
tpa_name
claimLanguage

Your personal information

Please provide us the following details
Driver's name*

First NameLast Name
Driver's date of birth*

DayMonthYear
Date
Country*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Policyholder details
Policy reference*
The reference mentionned on your vehicle's insurance certificate or 'green card'.
Is the policyholder different from the driver? *
entityType
Policyholder's first name *

First NameLast Name
Company's name*
Company number*
Vehicle registration plate number*
How many kilometres are on your car’s odometer?*

Accident information

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

DayMonthYear
Date
Hour Minutes
City of the accident location*
Street and number of the accident location*
Short explanation of the incident*
A third party holds you liable (another person asks you for compensation)
thirdPartyInvolved
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 (if available)

In case of a traffic accident, you must fill in one accident report with the other people involved in the accident.
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Please upload pictures of damages

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Please upload the police report

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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.
Do you agree with the privacy terms?*

Yes, I agree.
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.
Do you agree to the processing of your data (including sensitive data) by Qover?*

Yes, I agree.
Should be Empty:

Welcome to Fisker Insurance claim form

Your personal information

Policyholder details

Accident information

Documents

Data Protection, Fraud Prevention and Detection & Medical information