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Motor Third Party
Liability Insurance

Event notification by liable party

EVENT INFORMATION

Event date*

Event time

Event country

Event address ( address, city or GPS)*

Event circumstances*

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INFORMATION ABOUT LIABLE VEHICLE

Vehicle registration number*

Trailer registration number

INFORMATION ABOUT THIRD PARTY

Vehicle registration number/Property name

Was anyone injured?

SUPPORTING DOCUMENTS ( PROVIDE AVAILABLE ACCORDING TO THE LIST)

Accident report form/ Police report

This doesn't matter

Vehicle registration certificate

This doesn't matter

Driving licence

This doesn't matter

Vehicle damage photos

This doesn't matter

Photo from event place

This doesn't matter

DETAILS OF THE NOTIFIER

Notifier is the policyholder

Name

Surname*

Personal identification number/ Date of birth*

Address*

Phone number*

E-mail*

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 to receive information about promotions, discounts, bonuses and other marketing activities, including requests for my opinion about Balcia services. Choose

Motor Third PartyLiability Insurance

EVENT INFORMATION

INFORMATION ABOUT LIABLE VEHICLE

INFORMATION ABOUT THIRD PARTY

SUPPORTING DOCUMENTS ( PROVIDE AVAILABLE ACCORDING TO THE LIST)

DETAILS OF THE NOTIFIER

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Motor Third Party
Liability Insurance