Home Liability Incident Claim Form Incident Details Incident Details Claimant Name Your First Name Your Last Name Claimant Email Address Claimant Phone Number Lacrosse Club Name Date of Incident Description of Incident Incident Location (name and address of facility/field) Note: Coverage only applies to US Lacrosse, Inc. (dba USA Lacrosse, “USAL”) events involving USAL National teams, leagues, camps, clinics, tournaments, and officials and coaches associations, provided they follow 100% registered member guidelines set forth by USAL. Please include any relevant attachments (for example, third-party demand, correspondence from a legal firm, legal complaint, or similar document) if applicable. Unlimited number of files can be uploaded to this field.256 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, txt, rtf, pdf, doc, docx, xls, xlsx. CAPTCHA Math question 10 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. This is required for testing whether or not you are a human visitor and to prevent automated spam submissions.
Incident Details Incident Details Claimant Name Your First Name Your Last Name Claimant Email Address Claimant Phone Number Lacrosse Club Name Date of Incident Description of Incident Incident Location (name and address of facility/field) Note: Coverage only applies to US Lacrosse, Inc. (dba USA Lacrosse, “USAL”) events involving USAL National teams, leagues, camps, clinics, tournaments, and officials and coaches associations, provided they follow 100% registered member guidelines set forth by USAL. Please include any relevant attachments (for example, third-party demand, correspondence from a legal firm, legal complaint, or similar document) if applicable. Unlimited number of files can be uploaded to this field.256 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, txt, rtf, pdf, doc, docx, xls, xlsx. CAPTCHA Math question 10 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. This is required for testing whether or not you are a human visitor and to prevent automated spam submissions.
