Insurance Claim Form IFA-VTD (2016-2017)
Email address
Today's Date
Month / Day / Year = XX/XX/XXXX
Your answer
Team Name
Your answer
Team ID Number
Example: 17TTX12Y-000000
Your answer
Team Age Division
Please choose "only" one age group below
Head Coach Name
Head Coach name listed on roster
Your answer
Head Coach Phone Number
Please include Area Code
Your answer
Head Coach Email Address
Your answer
Injured Player Name
As shown on roster
Your answer
Injury Date
Date of Injury (Month/Date/Year) XX/XX/XXXX
Your answer
Injured Player Birthdate
Type the players birthdate in below. Example: (xx/xx/xxxx)
Your answer
Email Address for Claim Form to be Sent
Parent / Guardian Email for Injured Player
Your answer
Brief Description of injury
Short answer (35 words or less) of how injury occurred
Your answer
Please complete the captcha before submitting the form.
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