Procedures to File a Accident/Medical Insurance Claim

You can download a claim form by clicking here [Updated March 17, 2008].  Please do not use previous forms as they are obsolete.  You will need the Acrobat reader to display the form.  You can also obtain a medical claim from the NJYS Office.

Complete Sections I, II, IV, V and VI.  NJYS must complete Section III.

• The first line of Section 1 is the player and is the same as the patient.
• Be sure to enter your team name and club name on Line 1 of Section 2
• For travel team players make a copy of the team roster and photocopy of the player pass.
• If your player is also registered with another US Soccer organization, include a copy of your Accident/Medical claim form that you have submitted to that organization.
• Send the completed form to the NJYS office within 30 days of the injury.  Do not wait for bills from you medical service providers or payments made by your insurance carrier.

1. 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.

2. 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) to this claim form and mail to the New Jersey Youth Soccer office the address shown below.  Do not send the claim form directly to Bollinger. They will not accept a claim without the authorization of the NJYS Office.

3. Please check and make sure that:

a) You have completed and signed the Parent/Guardian or Insured’s Statement of other Insurance.

b) The Medical Records Authorization MUST be signed and dated. If you want payments to be sent directly to your doctor or healthcare provider, sign the Payment Authorization Section.

c) You have attached all unpaid bills to this form.

d) You have attached any Explanation of Benefits forms that you have received from your Primary insurance carrier or other healthcare plan.

e) You have completed only Sections I and II on the front of claim form.

4. Subsequent bills should be sent in as you receive them. Please write the claimant’s name, policy number and date of accident on all subsequent bills. A new claim form is not necessary.  Once the claim has been filed with NJYS, the bills may be submitted directly to:

Bollinger Insurance
Sports Claims Department
PO Box 390
Short Hills, NJ 07078-0390

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This page last modified on March 17, 2008
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