Defendant report

ACCIDENT INSURANCE

Notification of the event

EVENT INFORMATION

Accident or diagnosis of an illness

Date*

Time*

Country*

Was police notified?

Event circumstances*

Write text here…

INFORMATION ABOUT INSURED (injured) PERSON

Personal identification number or 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 (injured) person

Personal identification number/company code

Name Surname/company name

Bank account

SUPPORTING DOCUMENTS

Attach documents (medical statement, documents confirming the expenses, certificate of incapacity for work, etc.)

Attach a document

DETAILS OF THE NOTIFIER

Notifier is the insured (injured) person

Personal identification number*

Name*

Surname*

Address*

Phone number*

E-mail*

Read the Information Clause before submitting the form.

Select all

I agree that Balcia Insurance SE, acting through Poland branch, and its authorized third parties process my personal data related with health condition for the purposes of handling my claim application and calculating and paying insurance indemnity.