Policy change | Balcia

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

Type of inquiry

Change of personal data

Change of vehicle’s data

Other changes

Put the new data here

Please fill in only the fields that need to be changed.

Owner’s data

Co-owner’s data

Name

Last Name/Company name

Street

House Number

Flat number

City

Postal Code

Telephone

E-mail

Please fill in only the fields that need to be changed.

Make/model of vehicle

Registration numer

Vehicle registration date

VIN number

Additional information

Type your notification *

Add Attatchment

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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.

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Insurance details Please write Policy number

Notifier’s data

Type of inquiry

Put the new data here

Add Attatchment

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Insurance details