Balcia

Type of inquiry

I bought a car with Balcia insurance

I sold a car with Balcia insurance

Insurance details

Policy series and number *

Notifier’s data

Pesel *

Name *

Surname *

Telephone *

E-mail *

Give us your email so we can send you a confirmation of filing your case

Data of car owner

Private person

Company

Car owner’s PESEL *

Name *

Surname *

REGON of Car owner *

Company name *

Data of car buyer

PESEL/REGON of Car owner *

Name *

Last Name/Company name *

Street *

House Number *

Flat number

City *

Postal Code *

Telephone

E-mail

Co-owner

Data of co-owner

PESEL/REGON of Car co-owner *

Name *

Surname/Company *

Street *

House number *

Flat number

City *

Postal Code *

Telephone

Data of car sale

Time of car sale

Czy zbywca posiadał ubezpieczenie dobrowolne (AC, NNW, Assistance) w Balcia?

Tak

Nie

Dane do zwrotu przelewem:

Bank name *

Bank account number *

Name of the owner of the bank account *

Please attach the relevant document

Vehicle sales contract/VAT invoice of purchase/donation agreement/inheritance deed

Upload document

Read the Information Clause before submitting the form.

I consent to the transfer of documents and information related to the execution of the application by means of electronic communication, including telephone and e-mail.

I declare that the data I have provided are true.

Clear form

Type of inquiry

Insurance details Please write Policy number

Notifier’s data

Data of car owner

Data of car buyer

Data of co-owner

Data of car sale

Time of car sale

Czy zbywca posiadał ubezpieczenie dobrowolne (AC, NNW, Assistance) w Balcia?

Please attach the relevant document

Insurance details