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スポーツ保険申請フォーム
下記事項入力し送信お願いします
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Email
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氏名(選手名)
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郵便番号
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住所
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電話番号
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事故発生日(年月日と時刻)〈例:2021年5月16日15時〉
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事故の場所
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事故の詳細状況〈例:サッカーの練習中、シュートを打つ際に軸足を挫いて捻挫した〉
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ケガの部位
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ケガの種類(傷病名)
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医療機関名
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