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__extreme_junior_defendant_form.notice

__extreme_junior_defendant_form.event_notification

__extreme_junior_defendant_form.diagnosis_of_an_extreme_junior_or_illness

__extreme_junior_defendant_form.event_date

__extreme_junior_defendant_form.event_time

__extreme_junior_defendant_form.state_of_occurrence

__extreme_junior_defendant_form.was_it_reported_to_police

__extreme_junior_defendant_form.event_description

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__extreme_junior_defendant_form.information_about_insured_person

__extreme_junior_defendant_form.insured_personal_code_or_insurance_certificate_number

__extreme_junior_defendant_form.insured_name

__extreme_junior_defendant_form.insured_surname

__extreme_junior_defendant_form.insured_email

__extreme_junior_defendant_form.insured_phone

__extreme_junior_defendant_form.in_the_event_if_an_insured_event_transfer_the_insurance_benefit_to

__extreme_junior_defendant_form.beneficiary_coincides_with_the_insured

__extreme_junior_defendant_form.beneficiary_personal_company_code

__extreme_junior_defendant_form.beneficiary_first_name_last_name_company_name

__extreme_junior_defendant_form.beneficiary_bank_number

SUPPORTING DOCUMENTS

__extreme_junior_defendant_form.document_plus_info

__extreme_junior_defendant_form.attach_a_document

__extreme_junior_defendant_form.notifier_details

__extreme_junior_defendant_form.reporter_is_policy_owner

__extreme_junior_defendant_form.reporter_personal_code

__extreme_junior_defendant_form.reporter_name

__extreme_junior_defendant_form.reporter_surname

Address*

__extreme_junior_defendant_form.reporter_phone

__extreme_junior_defendant_form.reporter_email

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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