Balcia

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.

I confirm I have read the Privacy Policy, the information I have provided is correct and I am fully authorized to submit this claim application and, upon request of Balcia, I will provide other necessary data and documents. I am aware of and agree on the mutual communication (including document submission) via email.

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

* - Mandatory fields