Request for Filing Claim to Insurance
Form Provided by Missouri Youth Soccer Association
Full Name of Injured Player
Name of Member Club or League
Name of Team & Coach
Gender of Team
Age Group (birth year) of Team
Name of League or Tournament where injury occured
Name & Address of location where injury occured
Date and Time of Injury
Type of Injury (Be Detailed)
I understand that submission of this form must be within 90 days from date of injury and that submission does not guarantee acceptance by carrier.
I understand that policiy does not provide coverage for fields with "walls" (i.e. dasher boards as found on indoor soccer fields)
I affirm that my player is registered with Missouri Youth Soccer Association and was participating in a sanctioned event (if outside of Missouri a travel permit was acquired by team prior to play)
I understand that a copy of the player's signed USYS Medical Waiver must accompany the claim when submitted (may be obtained from coach or manager)
Name of Parent or Guardian Submitting Request:
Your e-mail for forms to be sent to:
Contact Phone Number:
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