Balcia

EVENT INFORMATION

Event date *

Event time *

Event country *

Address *

Event circumstances *

Bank name *

Type of credit card *

Information about card owner's data

Name *

Surname *

Personal code *

Phone number *

E-mail *

Bank account *

Information about the suffered person

Was there an suffered person?

Is the suffered person the credit card owner

Supporting documents

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, rar, zip, 7z, bmp, png.

Attach documents (documents confirming expenses, medical statement, photo of damages)

Upload document

Document *

Applicant Information

Notifier is the credit card holder

Notifier is the suffered person

Other

Name *

Surname *

Personal code *

Phone number *

E-mail *

Have you lodged a claim with another insurance company?

Yes

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.

credit card insurance

EVENT INFORMATION

Information about card owner's data

Information about the suffered person

Supporting documents

Attach documents (documents confirming expenses, medical statement, photo of damages)

Applicant Information

Have you lodged a claim with another insurance company?

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credit card insurance

EVENT INFORMATION

Information about card owner's data

Information about the suffered person Suffered person - the person for whom an application for compensation is submitted, in connection with the deterioration of health or medical expenses

Supporting documents

Attach documents (documents confirming expenses, medical statement, photo of damages)

Applicant Information

Have you lodged a claim with another insurance company?

Subscribe for newsletter!

Information about the suffered person