Terminate contract

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

Car owner’s PESEL *

Name *

Surname *

REGON of Car owner *

Company name *

Reason for termination

I am not renewing the policy for another insurance period

(of Art.28 par.1 of the Act on Compulsory Insurance relates to the termination of an insurance contract before the end of its term)

Termination of double insurance

(Art 28.1a par.1 of the Law on Compulsory Insurance applies when you have purchased insurance from another Insurance Company and our policy has been renewed)

I bought a car with Balcia insurance

( Art. 31 par.1 of the Law on Compulsory Insurance refers to the situation in which you have purchased a vehicle with a contract of motor third-party liability Balcia)

Withdraw from a remote agreement

(You can withdraw from the contract within 30 days of its conclusion)

Other

(Other reasons than listed above)

Reason why you want to cancel the insurance?

I don't need insurance anymore

I am not satisfied with service

I bought the wrong product

Other

Fill in the details if you want to get a premium refund:

Bank name

Bank account number

Name of the owner of the bank account

Attach a scan or photo of the withdrawal from the contract

To effectively withdraw from an insurance contract concluded remotely fill out and sign our template in your own hand - you can find it here.

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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.

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