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Insurance

TYPES OF INSURANCE

PROCEDURES TO FILE AN ACCIDENT/MEDICAL INSURANCE CLAIM

Please note a copy of the current player pass for travel, and a copy of your insurance card must be sent along with the claim form.

There is a $1000.00 deductable associated with this policy.

Any injuries after 9/1/18 use this claim form

Medical Claim form for the 2018-2019 seasonal year

Any injuries prior to 9/1/18 must use the claim form below.

Medical Claim form for the 2017-2018 seasonal year

You cannot use previous forms as they are obsolete and your claim will be returned to you. You will need the Acrobat reader to display the form.

You can also obtain an Accident/Medical claim from the NJYS Office.

  1. Complete ALL questions on the Youth Soccer Accident Claim Form.
  2. Have the coach or another local official that witnessed the accident sign Section III (COACH OR LOCAL OFFICIAL VERIFICATION).
  3. Sign the claim form in Section VI (STATEMENT OF CERTIFICATION/AUTHORIZATION TO RELEASE INFORMATION.)
  4. File this new report of claim within 90 days of the date of accident or as soon thereafter as is reasonably possible.
  5. If you have other insurance, submit your itemized bills to the other carrier first. You will receive a payment Explanation of Benefit worksheet (EOB) from your other carrier. Do NOT wait until your other carrier has processed all your bills before filing a Youth Soccer Accident Claim Form.
  6. You may attach itemized bills and your other carrier's EOBs that are ready at the time of submitting this Claim Form.
  7. Send the Claim Form to your State Association for verification and authorized state signature. DO NOT SEND THE CLAIM FORM DIRECTLY TO PULLEN INSURANCE SERVICES. Please email to lorie@njyouthsoccer.com
  8. Upon receipt of the claim form from your state association Mutual of Omaha will forward an acknowledgement form advising you of receipt of your claim. All future correspondence concerning your claim should be directed to Mutual of Omaha at the address and phone number listed on your acknowledgement.

Send the completed form to the NJYS office within 90 days of the injury. Do not wait for bills from you medical service providers or payments made by your insurance carrier.

Please include a copy of the referee report for the match the injury occurred if available.

IMMEDIATELY submit a claim for all medical expenses to the Company that administers your own personal or group insurance or healthcare plan (including Major Medical coverage). If you have coverage through an HMO or similar facility, you must use that facility first or the claim will not be covered under this policy.

After your other insurance or healthcare plan has paid the medical expenses up to the policy limits, attach any unpaid bills and copies of payments made by your insurance company (Explanation of Benefits) and mail to Pullen, Inc. at the address shown below.

All subsequent bills should be sent to K&K Insurance Group, Inc as you receive them. Please write the claimant's name and date of accident on all subsequent bills. A new claim form is not necessary. Bills that are sent to the NJYS office will only delay payment to your service provider. Once the claim has been filed with NJYS, any bills should be submitted directly to:

Pullen Insurance Services
2560 RIVER PARK PLAZA, SUITE 300
FORT WORTH, TEXAS 76116