Claims Information
Maryland State Youth Soccer Association
Administered by Bollinger and Glenn Miller Agency

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.