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INSURANCE

AYSO Insurance (SIA)

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. For a more detailed explanation of the plan see the SAI Brochure.

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)
    1. Copies of itemized insurance billing forms – UB04 or CMS1500

No Primary Insurance: If there is no other insurance avail¬able 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, 2016 and after:
SAI Brochure (English)
SAI Overview-1 page
SAI Claim Form with Instructions (English)
SAI Claim Form with Instructions (Spanish)

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

AYSO Incident Report Form - Fillable Form


PARTICIPATION RELEASE FORM

Whenever a player or youth volunteer has suffered a concussion or an injury or illness that required the care of a physician or a visit to an emergency care facility, the AYSO Participation Release Form must be given to the parents or guardians. The participation release form must be completed in full and signed by the child's parents or guardians before the player or youth volunteer will be allowed to participate further in the program.

This form protects not only AYSO, but more importantly, the participants. Too often participants are out playing again before they are physically ready. Players should not participate until they are ready to play again. This form should also be used in cases of major illness.

Directions for use:
  • The Regional Safety Director should enter the mailing information located in the lower portion of the form on a master copy of the form each year, and prepare copies for distribution or make the form downloadable from the Region's web site
  • One or several blank forms should be given to all team coaches as part of the materials provided them at the beginning of any season.
  • Tournament directors would be advised to have a supply on hand as well.
  • The form should be sent to the Regional Safety Director for filing, but could be retained by the coach for a week or so in the event anyone might question the participation of the player subsequent to an illness or injury. (At the Region's option a two part NCR version of the form could be produced so that the coach retains a copy and sends the original to the Regional Safety Director.)
  • The form is required whenever a player is removed from participation for concussion symptoms or it is known that the player has had to seek emergency room treatment or a physician office visit to treat an injury or illness affecting the player's readiness to participate.
  • Participation Release Forms for a Concussion and any accompanying Medical Release required by State law, must be forwarded to the National Office at [email protected].

Participation Release Form - Click for Form

SAFETY & RISK MANAGEMENT DIRECTOR

Leanne Pinheiro
P.O. Box 2274
Tulare, CA 93275
Email: [email protected]

INCIDENT REPORTING

The purpose of the AYSO Incident Report Form is to capture all pertinent facts and contact information, while the information is readily available, whenever there is a serious incident involving AYSO participants, activities, facilities or property.

When to file an Incident Report form?

Incident report forms should be completed by any coach, referee or Regional staff member witnessing any serious incident involving, but not limited to:

  • Injury
  • Threats of bodily harm
  • Fighting whether or not a serious injury occurs
  • Property damage
  • Hospitalization of a participant
  • Law enforcement summoned
  • Service or notification of a pending lawsuit

Send the completed Incident Report to:

Safety and Risk Management Director
Leanne Pinheiro
P.O. Box 2274
Tulare, CA 93275
Email: [email protected]

Please note: An Incident Report is required if you plan to utilize AYSO Region 255’s insurance claim. Parents are responsible to inform and request a copy of the incident report from their Coach, Safety Director, and Regional Commissioner.

AYSO Incident Report Form

GENERAL RELEASE FORM

Once the team coach has assumed charge of the children on his/her team, the coach remains responsible until a duly designated adult has taken charge of each child after a practice or game. No child shall be left unsupervised after a game or practice

AYSO does not encourage children to walk or ride a bicycle home or to a friend or relative's house. However, we recognize that it may be necessary in some cases. When it is, coaches should secure a general release form from the parents/guardians to ensure their approval. 

General Release Form - Click for Form

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Contact Us

AYSO Region 255

By Mail: P.O. Box 2274 - Tulare CA 93275, Elk Bayou Soccer Complex 5700 S. Laspina
Tulare, California 93274

Email Us: [email protected]
Phone : 559-422-7211
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