Youth Soccer Tips

Must have Adobe Acrobat Reader to view .pdf documents.

Frequently asked questions, forms and information regarding insurance are all on this page.

CYSA CASE REPORT (Fill-In Form) Posted: 06/20/2008

Note: The CYSA CASE REPORT must be completed and submitted into the CYSA State Office within ninety (90) days from the date of injury

PIM 05-1 CERTIFICATES OF INSURANCE

The CYSA Board of Directors shall have the authority to suspend the applicable certificate(s) of insurance and/or cancel any CYSA function if the hosting league or any sub-group of the hosting league operates an event that is not sanctioned by CYSA on the same dates using the same volunteer pool facilities and/or fields.

Insurance Summary

2007/2008 Insurance Summary English

2007/2008 Insurance Summary Spanish

1. Accident Insurance Program General Information:

   1. Who is covered?  All registered members, teams, and leagues of the California Youth Soccer Association, Inc.  This includes registered team members, employees, coaches, officials, managers, referees and volunteers of the teams, leagues or of the association.

   2. When are they covered?  The above participants are covered during sponsored and supervised activities of CYSA, such as games, practices, and tournaments and other sponsored activities.  In addition, excess accident insurance is provided for injuries sustained while traveling as a team directly to and from a CYSA sanctioned activity and traveling under the direct and immediate supervision of a team official.  Important note: CYSA's liability policy provides Hired and Non-Owned auto liability coverage, but only for travel on official business of CYSA.

*This is a full excess policy.  The benefits are payable in excess of any other Health Care Plan, (as defined in the policy) regardless of any coordination of Benefits provision contained in such Health Care Plan.  The medical expenses must be incurred within 156 weeks (3 years) of the date of injury and be reported within 90 days to the California Youth Soccer Association, Inc. of the day of injury.  A deductible of $250 will apply to each covered accident.  Claims will be paid on usual and customary basis.

2. What is not covered?  Notable exclusions under the accident policy are: self inflicted injuries; illness; hernia; and pre-existing conditions; charges which the covered person would not have to pay if he or she did not have insurance; travel in or upon any two or three wheeled motor vehicle, or any off-road motorized vehicle or snowmobile not requiring licensing as a motor vehicle; that part of medical expense payable by any automobile insurance policy without regard to fault; practice or play in any intercollegiate sports activity; eyeglasses, contact lenses, hearing aids, or examinations or prescriptions therefore; any loss which is covered by State or Federal worker's compensation, employer's liability, or occupational disease law; dental care or treatment other than care of sound, natural teeth and gum; and intoxication.

3. How to file an Accident Claim:

   In the event of an injury requiring medical treatment, you should:

   1. Obtain a CYSA Case Report from the CYSA State Office or your League.  You can also obtain it from our website www.cysanorth.org under Insurance, or in the back of the CYSA Team Manual.  Have your Coach, Asst. Coach, or Team Manager complete the form, and submit it to the CYSA State Office.

   2. CYSA will then send out a claim form (proof of loss) to the parent or guardian of the injured claimant.

   3. Parent or guardian will need to complete the Claim Form and include copies of all itemized bills.  The portion marked "To be completed by policyholder/administrator" must be completed by CYSA State Office.

   4. If you have no insurance coverage, you will need to have your employer verify by letterhead that you have no coverage through them.

   5. NOTE: This is an excess policy.  If you are covered by any other Health Care Plan or insurance plan, you must submit your bills to your other insurance carrier first.  After your other carrier has paid their share of the claim, you may then submit any remaining balances due under this plan.  Be sure to send copies of all invoices and the Explanation of Benefits forms form your other Health Care Provider with this claim form.

   6. Send the Claim form and all relevant materials to:

      California Youth Soccer Association, Inc.

      ATTN: Insurance Claims

      1040 Serpentine Lane, Suite 201

      Pleasanton, CA 94566-4754

      925.426.5437

      CYSA will verify the information and forward the claims onto Bollinger, the paln administrator, for processing and payment.

3. Underwriting Insurance Carrier:

Peoples Benefit Life Insurance Co.

AM Best Rated A+ XV

Policy # PST2546B

Effective 9-1-2007 to 9-1-2008

5. Summary of Liability Coverages:

6. General Program Information:

   1. Plan Administrator:

      Bollinger Inc.

      101 JFK Parkway

      Short Hills, NJ 07078

      Toll Free 1-800-350-8005  Fax: 973-921-2876  www.bollingersoccer.com

   2. License: Bollinger's California License #: 0274666

   This summary is intended as a brief description of coverage offered under this policy.  For a full description of the policy coverage, conditions and exclusions, please refer to the actual policy.