Knee Protection Program

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Select Brace Model: *

A22

Defiance

FullForce

Armor FourcePoint

Brace Number: *

Locate your brace number for: A22, or Defiance.

Patient Name: *

Parent of minor:

If patient is under 18 years of age, please provide the name of your parent or guardian.

Address: *

Address 2:

City: *

State: *

Zipcode: *

Country *

Email Address: *

Phone Number *

Name of surgical physician: *

Surgical Physician’s Phone Number:

In detail please explain in detail how the complete re-tear of the ACL occurred *

(for ex: Playing basketball while wearing the brace, went for a layup and upon landing the knee twisted and felt a pop )

Please note: Once a claim is submitted, all necessary documents must be received no later than 90 days from submission date.

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2900 Lake Vista Drive
Suite 200

Lewisville, TX 75067

800.321.9549

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