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ADULT INSURANCE CLAIM QUESTIONNAIRE by KerryBuckvic

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									                       ADULT INSURANCE CLAIM QUESTIONNAIRE
           THIS IS NOT A CLAIM FORM - DO NOT ATTACH BILLINGS TO THIS FORM



Date of Injury:                                   Field Name/Location:

Cal South League Name:


Injured Person:                                                       Team Name:

Cal South ID#:                                                           Player or      Manager/Coach

Address:                                                              Phone Number:

City:                                                                 Zip:

Email Address:                                                        Date of Birth:


Type of Play Involved:         Adult League Game          Adult Team Practice           Adult Tournament

Name of Cal South Adult Tournament:

Opponent Name:

Start Time of Event:                                  Time of Injury:

Name of League and/or Tournament Administrator:

Description of Injury & Cause:




Was the Injury reported on the Referee's Official Game Report?               Yes       No

Does injured party have Primary Insurance?         Yes       No
If Yes, Name of Insurance Company:


Please answer all questions completely and mail, fax or email to:
Cal South - 1029 S. Placentia Avenue, Fullerton, CA 92831 - Fax (714) 441-0715 - lwolfs@calsouth.com


        Submit Form by Email       Print Form to be Mailed or Faxed

								
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