Insurance Forms

When a player receives an injury during participation in a Kemptville District Soccer Club program some financial assistance may be available.

If the injury occurs during an Ontario Soccer sanctioned game (a game with a center referee assigned to the game) the injured player is advised to obtain a copy of the Game Sheet and of the Special Incident Report from the Club or League.

The Club does not submit claims on behalf of members, but will assist in any way possible.

To view an article on the Insurance Claim Process please click here. The process has been revised as of September 1, 2017.

To download the 5 page Claim Form please click here. Please note that the completed form and relevant receipts must be submitted to Chubb Life Insurance within 30 days of the injury.

For more information please email