Team Registration Insurance Claim Form

Team Registration Insurance Claims Form
Team Registration Insurance

Claims Form
Policy/Certificate Holder Information
Name*

First NameLast Name
Certificate Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Team Name*
Name of the Event/Tournament*
Claim Information
Summary of Incident*
Record/Proof of Incident*

Documentation to support the reason for no longer being able to participate or attend the activity - for example: documentation to show a travel delay or disruption
Cancelof
Copy of Event/Program Registration (e.g. registration receipt)*

Registration receipt showing the amount paid.
Cancelof
Copy of the Event Schedule*

Showing event date(s) and participation, e.g. game or bracket schedule
Cancelof
truefalse
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Team Registration Insurance Claims Form