Every year when Washington Youth Soccer families pay their club fees, a small amount of that fee goes towards "insurance," a benefit of being a member of Washington Youth Soccer.
What is Insurance?
Insurance provides Washington Youth Soccer Associations and Clubs with necessary coverage to allow them to book games and practices at public parks and fields, as well as secondary medical insurance for both players and coaches in the event of injury during a Washington Youth Soccer sanctioned event.
Who does it benefit?
In the event a player is injured during a Washington Youth Soccer sanctioned event, excess accident medical coverage helps families pay related costs above those covered by their primary insurance provider, less a $500 deductible. If the family does not have primary insurance, then their excess accident coverage would act as primary insurance, helping families through what could otherwise be a costly ordeal.
How does it work?
This claim form should only be completed by the Team Coach or Manager, preferably the Team Coach or Manager who was present at the time of the accident. No other person(s) are authorized to initiate a claim form. If someone other than the Team Coach or Manager submits the claim, it will be denied.
Disclaimer: The coach is initiating the claim form by entering details regarding the injured party (who/when/how/where) and the parent’s contact information. Once the claim has been reviewed, an email will then be sent to the parents with a document for their completion if they choose to proceed with a claim. It is then the parent’s responsibility to submit the completed claim form to the insurance company.
Follow the steps below to complete the Medical Insurance Form:
The parent should provide the following information to the Team Coach or Manager:
- Injured player’s name
- Injured player’s address
- Injured player’s date of birth
- Parent’s name
- Parent’s contact information (phone & email)
To complete the Online Medical Claim Form please click on the following link to access the Medical Claim Form from our insurance provider, Pullen Insurance: https://two.pullenins.com/WAS/WASOverview.asp. Please note that there is a $500 deductible.
A screen shot version of the full form: Medical Claim Form (see below)
After the Team Coach or Manager completes the form, a Confirmation of Submission email from Pullen Insurance will be sent to the injured person’s parent. The email address the confirmation will come from is firstname.lastname@example.org, so please check your spam filters if you have not received notice within 1 week.
Once approved, the parent will receive an email with the claim form as a PDF attachment. The parents will need to send the claim form to the insurer, Chartis / AIG, with the itemized medical provider bills and explanation of benefits (EOB) from the claimant’s primary insurance carrier (if applicable).
If the claim is denied by Washington Youth Soccer, the reason for the denial will be indicated in the Email Message box. An email will be sent to the parent or legal guardian indicating the reason for the denial.
Please feel free to contact Anya Rybnikova at AnyaR@washingtonyouthsoccer.org with any questions or concerns you may have regarding the online claims submission process.