Fillable Illinois Youth Soccer Insurance Claim Form printable pdf download

INSURANCE CLAIM FORM

SUBMIT WITHIN THIRTY (30) DAYS FROM DATE OF INJURY

SUBMIT THIS FORM TO YOUR LEAGUE FOR VERIFICATION BEFORE SENDING TO ILLINOIS YOUTH SOCCER!

INCOMPLETE CLAIMS WILL BE DISCARDED.

Illinois Youth Soccer (IYSA) does not accept, process, pay, approve, and/or verify insurance payments. Please complete and submit this IYSA Insurance Claim Form,

Youth Soccer Accident Proof of Loss Form, and copy of claimant’s IYSA Medical Release & Liability Waiver to the Illinois Youth Soccer Association within thirty (30)

days from the date of accident. DO NOT SUBMIT BILLS TO IYSA. Insurance company will reject all claims that have not been processed and approved by the IYSA.

The IYSA will reject all claims that have not been completed and signed by the Insured or parent/guardian for a minor, verifying coach and affiliated league. Do not wait

for the bills before filing a claim with the IYSA. IYSA coverage is secondary if Insured has primary insurance coverage. Benefits for Medical Expense within the policy

or certificate will be paid only for Medical Expense which is not recoverable from any other insurance policy, service contract or workers’ compensation. Failure by an

Insured to follow the terms and conditions of his/her primary coverage will result in a benefit reduction of eligible expense to Fifty Percent (50%) of the amount otherwise

payable. There is a $500 deductible. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or

statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a

fraudulent insurance act, which is a crime, and shall also be subject to a substantial civil penalty where and to the extent allowed by state law.

1. CONTACT YOUR PRIMARY INSURANCE CARRIER IMMEDIATELY & FOLLOW THEIR TERMS & CONDITIONS.

2. Have the coach and witness verify accident occurrence by his/her signature where indicated.

3. Obtain your League Officer’s signature on the IYSA Claim Form verifying that the Insured was a currently registered player in good standing with his/her IYSA

member league at and the IYSA at the time of the accident, that the accident occurred during IYSA member league approved youth soccer activity and that the Insured

provided written notice to the IYSA prior to participating in a non-IYSA activity in which the Insured was injured.

4. Complete and submit to IYSA this IYSA Insurance Claim Form as well as the Pullen Insurance Form found at

5. SUBMIT TO IYSA COPY OF INSURED’S IYSA MEDICAL RELEASE & LIABILITY WAIVER WITH CLAIM.

6. Keep copies of all documents and bills in the event that they are lost in the mail. DO NOT SUBMIT BILLS TO IYSA.

7. Incomplete and unsigned forms will be returned to the claimant.

8. The IYSA is not responsible for processing delays due to incomplete, improperly completed or returned claim forms and postal delays.

THIS SECTION TO BE COMPLETED BY INSURED

Date of Accident__________________________________________________Player’s Pass No._______________________________________________________

Insured’s Name________________________________________________________________Birthdate_______________________________________________

Street Address_________________________________________________________________________________________________________________________

City, State, Zip________________________________________________________________________________________________________________________

Home Phone(_____)_________________________Cell Phone(______)________________________ Email______________________________________

□

Team Name ________________________________________________________________________________________ U-___________

BOYS

GIRLS

Club Affiliation__________________________________________________IYSA League Affiliation__________________________________________________

I the undersigned Insured or parent/guardian (for a minor) hereby certify that the injury occurred in the indicated Illinois Youth Soccer Association, US Youth Soccer or

IYSA affiliated league activity and the information provided in the insurance claim is correct.

Insured or Parent/Guardian’s Signature for a minor__________________________________ Relationship to Minor___________________ Date_______________

THIS SECTION TO BE COMPLETED & SIGNED BY INSURED’S COACH

Verifying Coach’s Name___________________________________________________ Team Name ________________________________________U-_________

Coach’s Street Address__________________________________________________________________________________________________________________

City, State, Zip________________________________________________________________________________________________________________________

Primary/Cell Phone(________)__________________________ Email_________________________________________________________________

INDICATE ACTIVITY IN WHICH INJURY OCCURRED:

□LEAGUE GAME □TOURNAMENT □ STATE CUP □ PRACTICE □ Other____________________________________Date_____________________________

If injury occurred at Tournament, indicate TournamentName______________________________________________________________________________________

Tournament Location (City, State)_________________________________________________________________________ Date_____________________________

Describe Injury (Indicate left or right leg, foot, etc.)_____________________________________________________________________________________________

Describe How Injury Occurred______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

I, the undersigned team coach hereby certify that the claimant’s injury occurred in the above listed Illinois Youth Soccer Association, US Youth Soccer,or IYSA

affiliated league activity. Verifying Coach’s Signature____________________________________________________________ Date___________________________

THIS SECTION TO BE SUBMITTED TO AFFILIATED LEAGUE NOT IYSA FOR VERIFICATION

League Name__________________________________________________ League Official_________________________________

By my signature I verify that the Insured is currently registered and in good standing with the above listed IYSA affiliated league.

League Official’s Signature______________________________________ Title________________________ Date_______________

FOR ILLINOIS YOUTH SOCCER VERIFICATION ONLY

IYSA Official________________________________________________ Title________________________ Date______________

SEND COMPLETED FORM TO:

ILLINOIS YOUTH SOCCER ASSOCIATION - INSURANCE CLAIM

1655 S. ARLINGTON HEIGH ROAD, SUITE 201, ARLINGTON HEIGHTS, IL 60005

847/290-1577 847/290-1576(F)

CLAIM FORM REVISED 8/9/14

Illinois Youth Soccer Insurance Claim Form

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