Travel insurance

Event notification

EVENT INFORMATION

Event date*

Event time

Event country

Event circumstances*

Write text here…

INFORMATION ABOUT INSURED PERSON

Personal identification code / Insurance policy number*

Name*

Surname*

E-mail*

Phone number*

Please specify if you are insured with other insurance companies or have a bank credit card with insurance?

Provide the company's name

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

Beneficiary is the insured person

Personal identification number*

Name*

Surname*

Bank account*

SUPPORTING DOCUMENTS

Attach documents (documents confirming expenses, medical statement, certificate of lost luggage, etc.)

Attach documents

DETAILS OF THE NOTIFIER

Notifier is the insured person

Personal identification number*

Name*

Surname*

Address*

E-mail*

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.

* - Mandatory fields