Claims Information
U.S. Club Soccer - Youth

Online Form


TO BE COMPLETED BY CLAIMANT, PARENT OR GUARDIAN
Complete this form and press "Continue".  Items listed with a red asterisk (*) are required.

Insured Player's Information

*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip Code:
*Phone:
*Birth Date
*Gender: 
*Social Sec. #:
*Claimant is a:
Other:
    

Blank Claim Form

If you would like a blank claim form, please select your accident date below and then press “Print Blank Claim Form”.

*Accident Date




Instructions:

  1. Complete the claim form
  2. Once completed and signed, mail it to the address listed on the top left of the form.