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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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DD
/
YYYY
Injury Date *
04/10/2017
MM
/
DD
/
YYYY
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
MM
/
DD
/
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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