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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).

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Property insurance

EVENT INFORMATION

INFORMATION ABOUT POLICYHOLDER

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

SUPPORTING DOCUMENTS

DETAILS OF THE NOTIFIER

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