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
David Lans
1455 Melwood Dr.
Glendale CA 91207
Email: [email protected]

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. 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)
• 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.