Defendant report

CITY COMBO INSURANCE

Notification of the event

EVENT INFORMATION

Event date*

Event time

Event country*

Event address ( address, city)*

Was police notified?*

Were you injured?*

Other persons were injured or other property was damaged*

Event circumstances*

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INFORMATION ABOUT INSURED PERSON

Personal identification code/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 person

Personal identification code *

Beneficiary Name *

Surname*

Bank account*

SUPPORTING DOCUMENTS

Attach documents (documents confirming expenses, medical statement, photo of damages)

Attach documents

This doesn't matter

DETAILS OF THE NOTIFIER

Notifier is the insured person

Personal identification code*

Name*

Surname*

Address*

Phone number *

Email *

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.

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

CITY COMBO INSURANCE

EVENT INFORMATION

INFORMATION ABOUT INSURED PERSON

IN CASE OF THE INSURED EVENT, PLEASE TRANSFER THE INSURANCE BENEFIT TO

SUPPORTING DOCUMENTS

DETAILS OF THE NOTIFIER

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