Junior insurance plans

Title
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__extreme_junior_defendant_form.notice

__extreme_junior_defendant_form.event_notification

__extreme_junior_defendant_form.diagnosis_of_an_extreme_junior_or_illness

__extreme_junior_defendant_form.event_date

__extreme_junior_defendant_form.event_time

__extreme_junior_defendant_form.state_of_occurrence

__extreme_junior_defendant_form.was_it_reported_to_police

__extreme_junior_defendant_form.event_description

Write text here…

__extreme_junior_defendant_form.information_about_insured_person

__extreme_junior_defendant_form.insured_personal_code_or_insurance_certificate_number

__extreme_junior_defendant_form.insured_name

__extreme_junior_defendant_form.insured_surname

__extreme_junior_defendant_form.insured_email

__extreme_junior_defendant_form.insured_phone

__extreme_junior_defendant_form.in_the_event_if_an_insured_event_transfer_the_insurance_benefit_to

__extreme_junior_defendant_form.beneficiary_coincides_with_the_insured

__extreme_junior_defendant_form.beneficiary_personal_company_code

__extreme_junior_defendant_form.beneficiary_first_name_last_name_company_name

__extreme_junior_defendant_form.beneficiary_bank_number

SUPPORTING DOCUMENTS

__extreme_junior_defendant_form.document_plus_info

__extreme_junior_defendant_form.attach_a_document

__extreme_junior_defendant_form.notifier_details

__extreme_junior_defendant_form.reporter_is_policy_owner

__extreme_junior_defendant_form.reporter_personal_code

__extreme_junior_defendant_form.reporter_name

__extreme_junior_defendant_form.reporter_surname

Address*

__extreme_junior_defendant_form.reporter_phone

__extreme_junior_defendant_form.reporter_email

Select all

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 that Balcia Insurance SE, acting through Lithuanian 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 receive information about promotions, discounts, bonuses and other marketing activities, including requests for my opinion about Balcia services. Choose