PRESENTED BY: FLORIDA YOUTH SOCCER ASSOCIATION
and M.E. Wilson Co., Inc., PO Box 373, Tampa, FL 33601
(813) 229-8021
FAX: (813) 229-2795
Excess Accident coverage is automatically provided to registered members of the Florida Youth Soccer Association as part of the registration fee. The Accident policy provides coverage for registered players during sanctioned events, including regularly scheduled practices and games. This coverage is excess above the player’s own family health insurance. There is a $2,000 deductible on each claim. The insurance company will pay 80% of the eligible amount after the deductible has been applied. The claimant is responsible for the other 20% of the next $10,000 to a max out of pocket cost of $3000 per injury.
Coverages/Benefits: Accident-Medical $50,000 Maximum; Accidental Death $10,000 Principal Sum; Accidental Dismemberment $10,000 Maximum.
Complete the Youth Soccer Accident Proof of Loss (claim form), which is obtained from the Secure section of our website (through your club’s Agent of Record, President or Registrar). The form must be signed by the Coach, the Agent of Record from your club, and parent or legal guardian.
More information about FYSA insurance can be found here at the Bollinger website.
The fully completed, signed claim form must be returned for processing to:
M. E. Wilson Company, Inc.
P O Box 373
Tampa, FL 33601
· Be sure to include any itemized doctor bills as well as all Explanation of Benefits that you receive from your primary insurance carrier.
What keeps the Insurance Company from paying your claim?
· Incomplete or unsigned claim forms
· “Balance forward statements” from the Healthcare providers rather than Itemized Billings.
· Failure to provide your insurance company’s explanation of benefits.
PLEASE REMEMBER
You are responsible for the first $2,000 of your claim and 20% of the next $10,000 to a max out of pocket cost of $3000 per injury.
If you have any questions about reported claims, completing the claim form, or need additional copies of the claim form, feel free to call the FYSA Claims Department at M. E. Wilson Company, Inc.
1-888-229-8021
