Houstonians FC Injury Insurance Claim

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Complete this form to enter a claim for Houstonians FC Injury Insurance to cover training dues during the injury period. Players who have chosen to purchase Optional HFC Training Dues Injury Insurance for $25 only - other need not continue. This can only be purchased when the player makes their first Club Dues Payment. If the Injury Insurance was purchased, then a player is released from Club Dues payments during the months that they are medically unable to participate. If a player misses a month, due to an HFC related injury, then they will be released from that month's payment provided that they are current with their Club Dues at the time of the injury. As soon as the player returns to play, the payment for that month is expected. The Club Directors must be notified of the injury within 10 days of the diagnosis. A Doctor's note may be required. Injury Insurance is only valid for injuries that require a player to miss a month or more.

Name *

Birth date *

YYYY

Team Assignment *

Address *

Phone number *

Has the player been evaluated by a Physician? *

Yes

Do you have a note from the Physician stating that the player will not be able to participate for one month or more? *

Yes

Injury explanation (please include dates, times and details) *

Submit

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