Defendant report

Event date*

Event time

Event country

Event address ( address, city)*

Was anyone injured? *

How did the accident happen(detailed in chronological order)? * Example

Chronologically describe what happened, include other participant, weather etc. Describe the damage in details. If the police was notified, tell us what was the result of intervention. Ad inform us if perpetrator fled the scene or wasn’t authorized to drive.*

INFORMATION ABOUT LIABLE VEHICLE

Is driver the policyholder?

INFORMATION ABOUT THIRD PARTY

Vehicle registration number/Property name

Owner's name, surname/company name* *

Personal identification number/company code*

Address*

House/apartment number *

Postal code

Phone number*

E-mail*

Was police notified? *

Driver’s address *

Driver's apartment number

Driver's postal code

SUPPORTING DOCUMENTS ( PROVIDE AVAILABLE ACCORDING TO THE LIST)

The size of a single attached document should not exceed 5MB, and the maximum size of all documents should not exceed 30MB. Allowed file types: pdf, jpg, doc, xls, zip, 7z, bmp, png.

PLEASE CHOOSE THE METHOD OF COMPENSATION:

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 Party
Liability Insurance

EVENT INFORMATION

INFORMATION ABOUT LIABLE VEHICLE

Is driver the policyholder?

INFORMATION ABOUT THIRD PARTY

SUPPORTING DOCUMENTS ( PROVIDE AVAILABLE ACCORDING TO THE LIST)

PLEASE CHOOSE THE METHOD OF COMPENSATION:

Subscribe for newsletter!

Motor Third PartyLiability Insurance

EVENT INFORMATION

INFORMATION ABOUT LIABLE VEHICLE

Is driver the policyholder?

INFORMATION ABOUT THIRD PARTY

SUPPORTING DOCUMENTS ( PROVIDE AVAILABLE ACCORDING TO THE LIST)

PLEASE CHOOSE THE METHOD OF COMPENSATION:

Subscribe for newsletter!

Motor Third Party
Liability Insurance