Procedures to File an Accident/Medical Insurance Claim
You can download a CLAIM FORM - Updated September 1, 2018. 
You cannot use previous forms as they are obsolete and your claim will be returned to you. 

Please note a copy of the current player pass for travel, and a copy of your insurance card must be sent along with the claim form.

There is a $1000.00 deductable associated with this policy.

Any injuries prior to 9/1/18 must contact the NJYS office for last years claim form. 

You cannot use previous forms as they are obsolete and your claim will be returned to you. You will need the Acrobat reader to display the form.

You can also obtain an Accident/Medical claim from the NJYS Office.

1.       Complete ALL questions on the Youth Soccer Accident Claim Form.

2.       Have the coach or another local official that witnessed the accident sign Section III (COACH OR LOCAL OFFICIAL VERIFICATION).

3.       Sign the claim form in Section VI (STATEMENT OF CERTIFICATION/AUTHORIZATION TO RELEASE INFORMATION.)

4.       File this new report of claim within 90 days of the date of accident or as soon thereafter as is reasonably possible.

5.       If you have other insurance, submit your itemized bills to the other carrier first. You will receive a payment Explanation of Benefit worksheet (EOB) from your other carrier. Do NOT wait until your other carrier has processed all your bills before filing a Youth Soccer Accident Claim Form.

6.       You may attach itemized bills and your other carrier's EOBs that are ready at the time of submitting this Claim Form.

7.       Send the Claim Form to your State Association for verification and authorized state signature. DO NOT SEND THE CLAIM FORM DIRECTLY TO PULLEN INSURANCE SERVICES. Please email to [email protected]

8.       Upon receipt of the claim form from your state association Mutual of Omaha will forward an acknowledgement form advising you of receipt of your claim. All future correspondence concerning your claim should be directed to Mutual of Omaha at the address and phone number listed on your acknowledgement.

Send the completed form to the NJYS office within 90 days of the injury. Do not wait for bills from you medical service providers or payments made by your insurance carrier.

Please include a copy of the referee report for the match the injury occurred if available.

IMMEDIATELY submit a claim for all medical expenses to the Company that administers your own personal or group insurance or healthcare plan (including Major Medical coverage). If you have coverage through an HMO or similar facility, you must use that facility first or the claim will not be covered under this policy.

After your other insurance or healthcare plan has paid the medical expenses up to the policy limits, attach any unpaid bills and copies of payments made by your insurance company (Explanation of Benefits) and mail to Pullen, Inc. at the address shown below.

All subsequent bills should be sent to K&K Insurance Group, Inc as you receive them. Please write the claimant's name and date of accident on all subsequent bills. A new claim form is not necessary. Bills that are sent to the NJYS office will only delay payment to your service provider. Once the claim has been filed with NJYS, any bills should be submitted directly to:

Pullen Insurance Services
2560 RIVER PARK PLAZA, SUITE 300
FORT WORTH, TEXAS 76116

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http://www.njyslive.com/home.php?layout=5630133

Medical Insurance

WHAT

Pays for usual and customary medical care expenses for injuries occurring while traveling to, from, or during a sanctioned event that is under the direct supervision of a team or club official.

The coverage is excess to the injured person's own medical insurance. If the injured person does not have medical insurance, this coverage becomes the primary insurance.

LIMITS

·   $100,000 maximum per injury for a maximum of two years

·   $1000 deductible

·   $50,000 maximum dental benefit per claim

·   $5,000 maximum accidental death benefit per claim

·   $5,000 maximum accidental dismemberment benefit per claim

·   $2,000 maximum Physical Therapy & Chiropractic Services per claim

·   $50 limit per day for Physical Therapy

·   $1,000 maximum Prescriptions per claim

·   $1,000 maximum Durable Medical Equipment per claim

WHO IS PROTECTED

Registered players, volunteer registered coaches, volunteer referees, administrators, volunteers

WHAT IS EXCLUDED

·   Participation in a non-sanctioned event

·   Travel outside of New Jersey without permission to travel

·   Acts of War

·   Private Camps

·   Air travel other than as a fare paying passenger on a scheduled flight

WHO IS EXCLUDED

·   Assigned and paid ref

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http://www.njyouthsoccer.com/doclib/NJYSA%20Medical%20Outline%201718.pdf

 Excess Accident Medical Coverage Summary

Policyholder: New Jersey Youth Soccer Association

Insurance Carrier: AM Best Rated A+ (Superior) Insurance Company

Term of Coverage: September 1, 2017 – September 1, 2018

Eligibility: Registered players, try-out participants, coaches, managers, referees, officials, Olympic Development Program Administrators, staff members, team workers and volunteers while participating in activities sanctioned and approved by New Jersey Youth Soccer Association.

Covered Activities: While participating in scheduled games, team practice sessions, or sponsored activities, provided they are under the direct supervision of a team official, or at sanctioned local or national tournaments as a member of a contestant team. Includes organized and supervised group travel as authorized by the policyholder directly to and from a covered event.

Policy Benefits:

Excess Accident Medical Benefit Maximum $100,000 per Injury

Accident Medical Deductible $1,000 per injury

Benefit Period 104 weeks from the date of the accident

Dental Expense Max Benefit $50,000 per Injury**

Physical Therapy / Chiropractic Max Benefit $2,000 per Injury**; $50 max per visit

Prescription Drug Expense Max Benefit $1,000 per Injury**

Durable Medical Equipment Benefit $1,000 per Injury**

Accidental Death & Specific Loss $5,000

**Subject to Accident Medical Expense Deductible and Benefit Maximum.

The Accident Medical Benefit is full excess / secondary coverage. Benefits for Accident Medical Expense will be paid only for such expense(s) which are not recoverable from any other insurance policy, service contract or workers' compensation contract.

Notable Exclusions: (a) suicide, attempted suicide or intentionally self-inflicted injury while sane or insane; (b) Injuries caused by an act of declared or undeclared war; (c) Injuries received while in the armed service; (d) Injuries received while acting as a pilot or crew member; (e) Injuries resulting from air travel, except while as a passenger for transportation only; (f) Injuries resulting from the Insured's engagement in or attempt to commit a felony or being engaged in an illegal occupation; (g) Injuries received while under the influence of any controlled substance, unless administered on the advice of a Legally Qualified Physician; (h) Injuries received while Intoxicated as specifically defined in this provision; or (i) Injuries sustained while traveling other than as specifically stated in this provision.

THIS IS ONLY A VERY GENERAL REFERENCE TO WHAT COVERAGE(S) THE INSURANCE POLICY PROVIDES AND IS NOT INTENDED TO DESCRIBE ALL OF THE VARIOUS DETAILS PERTAINING TO THE INSURANCE. ACTUAL COVERAGES ARE DETAILED IN THE POLICY OF INSURANCE AND ARE ALWAYS SUBJECT TO TERMS, PROVISIONS, CONDITIONS, AND EXCLUSIONS AS CONTAINED THEREIN. YOU SHOULD NOT RELY UPON THIS GENERALIZED SUMMARY, BUT SHOULD CONSULT THE ACTUAL POLICY FOR A COMPLETE DESCRIPTION AND DETAILS REGARDING COVERAGE