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Insurance Claim Form for VTD Sports
This form allows VTD Sports to verify the player was on the roster on the date of injury and issue a signed claim form.
Team ID #18TTX14Y-800171
Example: 18TTX12Y-800423
Your answer
Injured Player Name
First and Last Name
Your answer
Injured Player Date of Birth
07/07/2007
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Injury Date
04/10/2017
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Email Address for Claim Form to be Sent
Parent / Guardian Email for Injured Player
Your answer
Today's Date
Month / Day / Year of request for claim form initiated
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/
DD
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YYYY
Team Name
Your answer
Team Age Division
Head Coach Name
First / Last Name
Your answer
Contact Phone Number
Head Coach or Parent/Guardian Number
Your answer
Brief Description of Injury
Short answer (35 words or less) of how injury occurred
Your answer
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