City Combo | File a claim

CITY COMBO INSURANCE

Event notification

EVENT INFORMATION

Event date*

Event time

Event country*

Event address ( address, city or GPS)*

Was police notified?*

Were you injured?*

Other persons were injured or other property was damaged*

Has your vehicle been registered?

Event circumstances*

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INFORMATION ABOUT INSURED PERSON

Personal identification code/Insurance policy number *

Name*

Surname*

E-mail*

Phone number*

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

Beneficiary is the insured person

Personal identification code *

Beneficiary Name *

Surname*

Bank account*

SUPPORTING DOCUMENTS

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

Attach documents

This doesn't matter

DETAILS OF THE NOTIFIER

Notifier is the insured person

Personal identification code*

Name*

Surname*

Address*

Phone number *

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

CITY COMBO 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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