Bollinger Lacrosse

New Page 2

General Information
Bollinger Insurance PO Box 390 Short Hills, NJ 07078	General Phone: 800-350-8005, press “5” for Lacrosse Sports Claims Phone: 866-267-0093 Fax: 973-921-2876 Web: www.BollingerLax.com www.BollingerInsurance.com

Please complete the form below.

Select A Category:
* Your Name:
* Your Email Address: (so we can respond to you)
* Team or League Name:
* How can we help you?:
If this is in regard to a claim, please indicate:
* Claimant Name:
* Date of Injury:
* Enter Security Code: (case sensitive)