Canastota AYSO, Region 1563

Insurance

Soccer Accident Insurance (SAI)

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. Download the SAI Brochure for more detailed explanation of the plan.

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 expense must be incurred within 90 days of covered accident;
  • all claims must be filed within 90 days;
  • each claim is subject to a $200 Deductible; and
  • social security numbers, visa or green card are REQUIRED on SAI claim.
  • Claims will require:
    • Copies of primary Explanation of Benefits (EOB)
    • Copies of itemized insurance billing forms – UB04 or CMS1500
  • No Primary Insurance: If there is no other insurance availĀ­able 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
    • $10,000 for Orthopedic Benefit
    • $1,000 Physical Therapy

All AYSO currently registered* members (players, coaches, referees and other volunteers) 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.
  • Group travel of five or more participants directly, without interruption to or from such practice sessions, games, tournaments, or sponsored 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.

SAI Claim Forms & Brochures


Incident Report Form

The AYSO Incident Report Form is used whenever there is a personal injury, damaged property, or threats of or actual physical violence surrounding an AYSO game, practice, event or property. The form should be prepared by the Coach, AYSO Official, or other AYSO Volunteer. The form may also be prepared by a member of the regional staff such as the regional safety director, or by tournament or event staff members. 

Incident Report Form with Instructions