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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