Website Manager

American Youth Soccer Organization Providing world class youth soccer programs that enrich children's lives.

AYSO Region 42 – Newbury Park, CA

Soccer Accident Insurance Claim Form - SAI

Soccer Accident Insurance- updated benefit information effective July 1, 2021.

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 or dental expense must be incurred within 90 days of covered accident;
  • all claims 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
  • No 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.

For Injuries occurring on JULY 1, 2021 and after:

2021-2022 SAI Brochure – Overview

2021-2022 SAI Brochure

2021 – 2022 Claim Form – English

2021 – 2022 Claim Form – Spanish

If you have any questions or need assistance, please contact Darryl Levi, Region 42 Safety Director

National Partners

Our sponsors

Contact Us

AYSO Region 42 – Newbury Park, CA

P.O. Box 709 
Newbury Park, California 91319

Email Us: [email protected]
Copyright © 2021 Region 42  |  Privacy Statement |  Terms Of Use |  License Agreement |  Children's Privacy Policy  Login