Defendant report

TRAVEL INSURANCE

Notification of the event

EVENT INFORMATION

Event date*

Event time

Event country

Event circumstances*

Write text here…

INFORMATION ABOUT INSURED PERSON

Personal identification code / Insurance policy number*

Name*

Surname*

E-mail*

Phone number*

Please specify if you are insured with other insurance companies or have a bank credit card with insurance?

Provide the company's name

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

Beneficiary is the insured person

Personal identification number*

Name*

Surname*

Bank account*

SUPPORTING DOCUMENTS

Attach documents (documents confirming expenses, medical statement, certificate of lost luggage, etc.)

Attach documents

DETAILS OF THE NOTIFIER

Notifier is the insured person

Personal identification number*

Name*

Surname*

Address*

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.

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

TRAVEL 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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