2009-2010 Insurance Claim procedures

General Information on the Liability/Accident Insurance Program

PROOF OF LIABILITY INSURANCE REQUEST FORM

In the event the owners or operators of game and practice facilities require proof of liability insurance before allowing member organizations to use those facilities, you can request a certificate from EPYSA by complete the request form and return it to EPYSA, 2 Village Road, Suite # 3, Horsham, PA 19044.

CERTIFICATE(S) WILL NOT BE ISSUED WITHOUT A WRITTEN REQUEST.

INSURANCE VERIFICATION FORM

This is the form that some of the Tournaments require to make sure the teams are insured. Please complete the form and return it to EPYSA, 2 Village Road, Suite # 3, Horsham, PA 19044.

MEDICAL INSURANCE COVERAGE

Bollinger General Insurance Information

How to file a claim

Please complete the enclosed claim forms:

EPYSA claim form

Bollinger Insurance Claim Form (Complete the online form, print it out and send it along with the EPSYA Claim Form)

Return these 2 forms along with your itemized bills, explanation of benefits (EOB's) from your primary carrier and any cancelled checks for bills you have paid relating to this injury. You should send in the claim form as soon as possible (within 30 days from date of injury). You may send just the claim form and have the Explanation of Benefit's (EOB's) follow at a later date. The important thing is to have the claim on file. You may continue to send any other bills; EOB's, etc. as you receive them, just enclose a note stating that the claim is already on file.

If you do not have primary insurance coverage, please write a letter stating that you did not have any medical insurance at the time of the injury. This letter must be notarized and returned with all itemized bills to the EPYSA office.

Medical coverage for Travel Teams is paid through the Primary League they participate in. Recreational Clubs are paid through the League they play in. Intramural Leagues pay EPYSA directly. If your club/league purchased the coverage, then there is a $100.00 deductible (this $100.00 is not applied towards your primary deductible, you will have $100.00 deducted from the amount you are requesting for refund.) You should check with your organization before completing the paperwork for a claim.
The cost of the medical insurance is $25.00 per team.

If you have any questions, please call 215-657-3795 or e-mail Beck at Beck.kleinert@epysa.org.