If, during a CYSA sanctioned game or practice, a player suffers a significant injury requiring medical attention, the player is covered with supplemental medical insurance under CYSA.  The supplemental insurance can help to defray medical costs not paid by a player’s primary medical insurance.

The instructions below outline how to file a claim using the Case Report Form.

How to file an Accident claim:

In the event of an injury requiring medical treatment you should:

A. Obtain a Youth Soccer Case Report from the CYSA State Office or your League.  You can also go to our website – www.CYSAnorth.org under Insurance or in the back of the CYSA Team Manual, Insert H. Have your Coach, Asst. Coach, or Team Manager complete the form, and submit it to the CYSA State Office.

B. CYSA will then send out a claim form (proof of loss) to the parent or guardian ofthe injured claimant.

C. Parent or guardian will need to complete the Claim Form and include copies of all itemized bills. The portion marked “To be completed by policyholder/administrator” must be completed by the CYSA State Office.

D. If you have no insurance coverage you will need to have your employer verify by letterhead that you have no coverage through them.

E. NOTE: This is an Excess Policy. If you are covered by any other Health Care Plan or insurance plan, you must submit your bills to your other insurance carrier first. After your other carrier has paid their share of the claim, you may then submit any remaining balances due under this plan. Be sure to send copies of all invoices and the Explanation of Benefits forms from your other Health Care Provider with this claim form.

F. Send the claim form and all relevant materials to:

California Youth Soccer Association, Inc.

ATTN: Insurance Claims
1040 Serpentine Lane, Suite 201 

Pleasanton, CA 94566-4754

Phone 925.426.5437

CYSA will verify the information and forward the claims onto Bollinger, the plan administrator, for processing and payment.