Universal claim notification form

universal claim notification form

Event notification

EVENT INFORMATION

Event date*

Event time

Event country*

Event address ( address, city)*

Event circumstances*

Write text here…

INFORMATION ABOUT POLICYHOLDER

Insurance policy number *

Name Surname or Company name*

E-mail*

Phone number*

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

Beneficiary is the policyholder

Personal identification number/company code

Name Surname/company name

Bank account

SUPPORTING DOCUMENTS

Attach documents (photo of damages, third parties claims document, other)

Attach documents

This doesn't matter

Details of the notifier

Notifier is the policyholder

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