Defendant report

universal claim notification form

Notification of the event

EVENT INFORMATION

Event date*

Event time

Event country*

Event address ( address, city)*

Event circumstances*

Write text here…

INFORMATION ABOUT POLICYHOLDER

Insurance policy number *

Name Surname or Company name*

E-mail*

Phone number*

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

Beneficiary is the policyholder

Personal identification number/company code

Name Surname/company name

Bank account

SUPPORTING DOCUMENTS

Attach documents (photo of damages, third parties claims document, other)

Attach documents

This doesn't matter

Details of the notifier

Notifier is the policyholder

Personal identification number*

Name*

Surname*

Address*

Phone number*

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.