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Soccer Accident Insurance Claim Form – SAI

Soccer Accident Insurance-Updated benefit information effective July 1, 2017

AYSO purchases Soccer Accident Insurance (“SAI”), which pays excess medical costs up to $50,000 maximum per accident to an insured person for accidental bodily injuries incurred as a direct result of participation in a covered activity subject to the policy terms, conditions and exclusions. Eligibility for benefits is 52 weeks from the policy effective date or the date of a covered accident. Download the SAI Brochure below for more detailed explanation of the plan. Accident Medical Expense Benefits are only payable:

  • For usual and customary charges incurred after the deductible has been met;
  • For those medically necessary covered expenses that the covered person receives;
  • First medical or dental expense must be incurred within 90 days of covered accident;
  • Proof of loss must be filed within 90 days;
  • Each claim is subject to a $1000 Deductible; and 20% member Coinsurance;

Claims will require:

  • Copies of primary Explanation of Benefits (EOB)
  • Copies of itemized insurance billing forms – UB04 or CMS1500

Primary Insurance: If there is no other insurance available to the registered member, the medical benefit will be processed on a primary basis subject to Usual and Customary rates, and the policy terms, conditions and exclusions.

MAXIMUM BENEFITS PAYABLE:(subject to policy terms, conditions & limits)

  • $50,000 maximum excess medical costs
  • $15,000 for Accidental Death & Dismemberment
  • $10,000 for Dental Benefit for injuries to sound natural teeth
  • $10,000 for Orthopedic Benefit
  • $1,000 Physical Therapy; $100 per day up to 10 days

All AYSO currently registered* members (players, coaches, managers, team workers, referees, officials and volunteer workers) are “Covered Persons” for accidental bodily injury while participating in the following covered activities:

  • Team practice sessions, scheduled games, tournaments, or other sponsored activities (meetings, banquets, fundraisers) provided they are under the direct supervision of an AYSO registered volunteer.
  • Travel of covered members to and from a sponsored activity such as practice sessions, games, tournaments, or AYSO sanctioned activities, provided that players are traveling as a team and a licensed adult driver operates the vehicle.

Registration requirements will be verified before any benefits are paid.

For injuries occurring on July 1, 2018 and after:

2018 SAI Brochure (English)
2018 SAI Brochure Overview (English)
2018 AYSO SAI Claim Form-Reg Rev 06-2018
2018 AYSO SAI Claim Form (Spanish)

 

*Registration requirements will be verified before any benefits are paid.