Request for Filing Claim to Insurance for 2019/2020 Season Only
Form Provided by Missouri Youth Soccer Association
Full Name of Injured Player *
Your answer
Name of Member Club or League *
Your answer
Name of Team *
Your answer
Name of Head Coach *
Your answer
Gender of Team *
Age Group (birth year) of Team *
Your answer
Name of Event, League or Tournament where injury occurred *
Your answer
Name & Address of location where injury occured *
Your answer
Date and Time of Injury *
Your answer
Type of Injury (Be Detailed)
Your answer
I understand that submission of this form must be within 45 days from date of injury and that submission does not guarantee acceptance by carrier. DO NOT WAIT for medical bills *
Required
I understand that policy does not provide coverage for fields with "walls" (i.e. dasher boards as found on indoor soccer fields) *
Required
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) *
Required
Name of Parent or Guardian Submitting Request: *
Your answer
Your e-mail for forms to be sent to: *
Your answer
Contact Phone Number: *
Your answer
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