Reporting an Injury (ENYYSA)

When reporting an injury, the following procedures should be taken:

  1.  The Advance Notice of Injury form must be completed by the Coach (who was present when injury occurred) and submitted to your League. Note: You have 30 days from date of injury to submit the claim form. For claims to be eligible for coverage you must seek medical attention within 60 days from the date of injury.
  2. The League then verifies that the player is registered and that the injury occurred at a sanctioned ENYYSA event. Once verified, the League approves and forwards to the ENYYSA State Office.
  3. ENYYSA receives the Advance Notice of Injury form from the League, reviews and approves. The Claim Form is forwarded to the parent / guardian via e-mail. It is important that you include a current e-mail address on the form.
  4. The parent / guardian must complete the Claim Form and return to the ENYYSA State Office for processing. If the Claim Form is not returned a claim will not be filed with the Insurance carrier.
  5. ENNYSA forwards the Claim Form to the Insurance carrier.
  6. At this point, inquiries should be directed toward the insurance carrier at (817) 738-6100.
  7. When submitting bills to our insurance carrier, please ensure the following:
    • Each itemized bill MUST show the following:
      • Provider of Service’s Name
      • Date of Service
      • Provider’s Address
      • Diagnosis Description or Codes (ICD-9)
      • Provider’s Federal Tax ID# • Procedure Description or Codes (CPT)
      • Provider’s Telephone #
      • Charge for each Procedure
    • Additional bills to be submitted at a later date (after the initial submission of your claim) should be mailed directly to Chartis Insurance with the following information:
      • Name of the claimant
      • Date of the accident
      • Eastern New York Youth Soccer Association

Please respond promptly to any correspondence requesting additional information. It is the Parent / Guardian / Claimant’s responsibility to request this information from the provider of service or from your primary carrier.

An Explanation of Benefits will be sent to you by Chartis/AIG Insurance. Note: There is a $500 deductible per covered accident, with an 80% reimbursement.

Expenses of Physical Therapy and Chiropractic Care limited to $50 per visit.

Please send completed form to Diana Knight at diana@enysoccer.com.

ENYYSA ADVANCED NOTICE INJURY CLAIM FORM
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