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 identification 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 identification code*

Name*

Surname*

Address*

Phone number *

Email *

Select all

I confirm I have read the Privacy Policy and its content is clear and understandable to me. I agree that Balcia and its authorized third parties process my personal data (including health-related data) in order to administrate my claim and calculate and pay the insurance indemnity.

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 and other Balcia marketing activities, including asking for my opinion about the services of Balcia. Show more