Accident insurance

Event notification

EVENT INFORMATION

Accident or diagnosis of an illness

Date*

Time*

Country*

Was police notified?*

Event circumstances*

Write text here…

INFORMATION ABOUT INSURED (injured) PERSON

Personal code/ Insurance policy number*

Name*

Surname*

E-mail*

Phone number*

IN CASE OF THE INSURED EVENT, PLEASE TRANSFER THE INSURANCE BENEFIT TO

Beneficiary is the insured (injured) person

Personal code/company code

Name Surname/company name

Bank account

SUPPORTING DOCUMENTS

Attach documents (medical statement, documents confirming the expenses, certificate of incapacity for work, etc.)

Attach a document

DETAILS OF THE NOTIFIER

Notifier is the insured (injured) person

Personal code*

Name

Surname*

Address*

Phone number*

E-mail*

Select all

I confirm I have read the Privacy Policy, the information I have provided is correct and I am fully authorized to submit this claim application and, upon request of Balcia, I will provide other necessary data and documents. I am aware of and agree on the mutual communication (including document submission) via email.

I have been open and truthful in providing all the necessary information. I don’t object that means of distance communication are used for mutual communication (including the transmission of documents).

I agree to receive information about promotions, discounts, bonuses and other marketing activities, including requests for my opinion about Balcia services. Choose