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For members registered with the AYSO National Support & Training Center

Contact: Holly Veach, AYSO NSTC
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Phone:
800-872-2976
Fax: 310-643-5310

Contact: Rhoda Wilson, HRH, 6am-2pm PST
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Phone: 800-365-4022
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SOCCER ACCIDENT INSURANCE CLAIM FORM W/INSTRUCTIONS 
(21 K)
Download (English Version) | Download (Spanish Version)

The Soccer Accident Insurance (“SAI”) underwritten by QBE Insurance Corporation, pays medical costs up to $50,000 maximum per claim to an insured person for accidental bodily injuries incurred as a direct result of participation in a covered activity. This is a Full Excess Policy, and all claims will be paid on a Usual & Customary basis.

Each claim is subject to a $200 Deductible

Other benefits under the policy are:
$10,000 for Accidental Death & Dismemberment
$3,500 for dental expenses resulting from accidental injury or loss to sound, natural teeth
$50,000 Maximum Medical Expenses
$1,000 Physical Therapy and Chiropractic Limit

  Expanded Medical Benefit: The policy will include coverage for Eligible Expenses resulting from conditions (such as blisters, tennis elbow, heat exhaustion, hernia, shin splints, bursitis, stress fractures, chronic soreness or pain, tendonitis, strains, sprains, etc.) which are a normal, foreseeable result of a sports or policyholder function covered under the terms of the policy.

  Heart or Circulatory System Malfunction Benefit: The policy will include coverage for Eligible Expenses incurred by a Covered Person as a result of heart or circulatory system malfunction which: Is first diagnosed and treated while participating in a Policyholder's covered Sponsored Activity (or within 24 hours after participation); and The Covered Person has not previously received medical advice, diagnosis and care or treatment, including the use of prescription drugs for such heart or circulatory system malfunction. If the Covered Person suffers loss of life resulting from heart or circulatory system malfunction within 90 days from the date of participation in the Policyholder's covered Sponsored Activity, a benefit amount is payable as shown under the Principal Sum of the Accidental Death & Dismemberment Benefit.

  Pre-existing Injury Benefit: The policy will include coverage for Eligible Expenses resulting from re-injury or aggravation of an injury that occurred prior to the effective date of this policy. In order to be eligible for this coverage, the Covered Person must: Have received a written medical clearance from a Doctor to participate in the covered Policyholder's function or sport; and be participating in a covered Policyholder's function or sport when the re-injury or re-aggravation occurs.

Who is covered?

  All AYSO registered players, coaches, referees, and volunteers are covered for accidental bodily injury while participating in the following activities:

  Scheduled games, tournaments, team practice sessions or other sponsored activities, provided they are under the direct supervision of a team official.

  Group travel directly to or from such games, tournaments, practice sessions or sponsored activities, provided that players are traveling as a team and a licensed adult driver operates the vehicle.

  If you or your parents are covered by any other health care plan, you must submit your bills to the other plan first. After your other plan has paid their share of the claim, you may then submit any remaining balances to the AYSO plan. Be sure to send copies of all itemized bills and the Explanation of Benefits Form outlining the benefits paid under your primary plan.

What is covered?

Medical/surgical treatment by a doctor or dentist
Services of a licensed or graduate nurse
Stays in a hospital

What is not covered?

Costs of medical services or treatment given by any persons employed or retained by the insured
Any bacterial infection not caused by an accidental cut, wound or food poisoning
Declared or undeclared acts of war
Any loss caused by or resulting from illness or disease
Eyeglasses, contact lenses or Hearing aids
Intentionally self-inflicted wounds, suicide (while sane or insane) or attempted suicide
LAST_UPDATED2
 
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AYSO Accident Insurance PDF Print E-mail
Information Center - Safety, Advice and Other Information

Copied From Click Here

For members registered with the AYSO National Support & Training Center

Contact: Holly Veach, AYSO NSTC
Email: This e-mail address is being protected from spambots, you need JavaScript enabled to view it This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
Phone:
800-872-2976
Fax: 310-643-5310

Contact: Rhoda Wilson, HRH, 6am-2pm PST
Email: This e-mail address is being protected from spambots, you need JavaScript enabled to view it This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
Phone: 800-365-4022
This e-mail address is being protected from spam bots, you need JavaScript enabled to view it \n This e-mail address is being protected from spambots, you need JavaScript enabled to view it This e-mail address is being protected from spam bots, you need JavaScript enabled to view it



SOCCER ACCIDENT INSURANCE CLAIM FORM W/INSTRUCTIONS 
(21 K)
Download (English Version) | Download (Spanish Version)

The Soccer Accident Insurance (“SAI”) underwritten by QBE Insurance Corporation, pays medical costs up to $50,000 maximum per claim to an insured person for accidental bodily injuries incurred as a direct result of participation in a covered activity. This is a Full Excess Policy, and all claims will be paid on a Usual & Customary basis.

Each claim is subject to a $200 Deductible

Other benefits under the policy are:
$10,000 for Accidental Death & Dismemberment
$3,500 for dental expenses resulting from accidental injury or loss to sound, natural teeth
$50,000 Maximum Medical Expenses
$1,000 Physical Therapy and Chiropractic Limit

  Expanded Medical Benefit: The policy will include coverage for Eligible Expenses resulting from conditions (such as blisters, tennis elbow, heat exhaustion, hernia, shin splints, bursitis, stress fractures, chronic soreness or pain, tendonitis, strains, sprains, etc.) which are a normal, foreseeable result of a sports or policyholder function covered under the terms of the policy.

  Heart or Circulatory System Malfunction Benefit: The policy will include coverage for Eligible Expenses incurred by a Covered Person as a result of heart or circulatory system malfunction which: Is first diagnosed and treated while participating in a Policyholder's covered Sponsored Activity (or within 24 hours after participation); and The Covered Person has not previously received medical advice, diagnosis and care or treatment, including the use of prescription drugs for such heart or circulatory system malfunction. If the Covered Person suffers loss of life resulting from heart or circulatory system malfunction within 90 days from the date of participation in the Policyholder's covered Sponsored Activity, a benefit amount is payable as shown under the Principal Sum of the Accidental Death & Dismemberment Benefit.

  Pre-existing Injury Benefit: The policy will include coverage for Eligible Expenses resulting from re-injury or aggravation of an injury that occurred prior to the effective date of this policy. In order to be eligible for this coverage, the Covered Person must: Have received a written medical clearance from a Doctor to participate in the covered Policyholder's function or sport; and be participating in a covered Policyholder's function or sport when the re-injury or re-aggravation occurs.

Who is covered?

  All AYSO registered players, coaches, referees, and volunteers are covered for accidental bodily injury while participating in the following activities:

  Scheduled games, tournaments, team practice sessions or other sponsored activities, provided they are under the direct supervision of a team official.

  Group travel directly to or from such games, tournaments, practice sessions or sponsored activities, provided that players are traveling as a team and a licensed adult driver operates the vehicle.

  If you or your parents are covered by any other health care plan, you must submit your bills to the other plan first. After your other plan has paid their share of the claim, you may then submit any remaining balances to the AYSO plan. Be sure to send copies of all itemized bills and the Explanation of Benefits Form outlining the benefits paid under your primary plan.

What is covered?

Medical/surgical treatment by a doctor or dentist
Services of a licensed or graduate nurse
Stays in a hospital

What is not covered?

Costs of medical services or treatment given by any persons employed or retained by the insured
Any bacterial infection not caused by an accidental cut, wound or food poisoning
Declared or undeclared acts of war
Any loss caused by or resulting from illness or disease
Eyeglasses, contact lenses or Hearing aids
Intentionally self-inflicted wounds, suicide (while sane or insane) or attempted suicide
LAST_UPDATED2