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Youth Soccer Accident Medical Claim Form

Attention: This claim form should only be completed by the claimant (injured person) or parent / legal guardian (if claimant is under the age of 18). No other person(s) are authorized to initiate a claim form.

Fraud Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant.

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***By logging into this system you certify that you are the claimant or the claimant’s parent / legal guardian (if claimant is under the age of 18) and you have read the above fraud warning***