Balcia

CASCO INSURANCE

Notification of the event

EVENT INFORMATION

Event date*

Event time

Event country

Event address ( address, city or GPS)*

Event circumstances* Example

Write text here…

VEHICLE INFORMATION

Vehicle registration number*

SUPPORTING DOCUMENTS ( PROVIDE AVAILABLE ACCORDING TO THE LIST)

Accident report form/ Police report

This doesn't matter

Vehicle registration certificate

This doesn't matter

Driving licence

This doesn't matter

Vehicle damage photos

This doesn't matter

Photo from event place

This doesn't matter

DETAILS OF THE NOTIFIER

Notifier is the policyholder

Name*

Surname*

Personal identification number/Date of birth*

Address*

House/apartment number *

Postal index *

Phone number*

E-mail*

PLEASE CHOOSE THE METHOD OF COMPENSATION:

Please estimate the damage value and transfer to

Przed wysłaniem formularza zapoznaj się z Obowiązkiem Informacyjnym

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.

I agree to recieve marketing activities and promotions about discounts and other bonuses.

* - Mandatory fields