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Copied From Click Here For members registered with the AYSO National Support & Training Center Contact: Holly Veach, AYSO NSTC Email: \n
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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: \n
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This e-mail address is being protected from spam bots, you need JavaScript enabled to view it Phone: 800-365-4022
All other questions related to insurance claims, please email \n
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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.
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