Defendant report

Motor Third Party
Liability Insurance

Event notification by liable party

EVENT INFORMATION

Event date*

Event time

Event country

Event address ( address, city)*

Event circumstances*

Write text here…

INFORMATION ABOUT LIABLE VEHICLE

Vehicle registration number*

Trailer registration number

INFORMATION ABOUT THIRD PARTY

Vehicle registration number/Property name

Was anyone injured?

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*

Phone number*

E-mail*

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

Motor Third PartyLiability Insurance

EVENT INFORMATION

INFORMATION ABOUT LIABLE VEHICLE

INFORMATION ABOUT THIRD PARTY

SUPPORTING DOCUMENTS ( PROVIDE AVAILABLE ACCORDING TO THE LIST)

DETAILS OF THE NOTIFIER

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Motor Third Party
Liability Insurance