City combo insurance

Event notification

EVENT INFORMATION

Event date*

Event time

Event country*

Event address ( address, city or GPS)*

Was police notified?*

Were you injured?*

Other persons were injured or other property was damaged*

Has your vehicle been registered?

Event circumstances*

Write text here…

INFORMATION ABOUT INSURED PERSON

Personal identification 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 person

Personal code *

Beneficiary Name *

Surname*

Bank account

SUPPORTING DOCUMENTS

Attach documents (documents confirming expenses, medical statement, photo of damages)

Attach documents

This doesn't matter

DETAILS OF THE NOTIFIER

Notifier is the insured person

Personal code*

Name*

Surname*

Address*

Phone number *

Email *

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