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Claim Form Procedures

Medical Claim Procedures

1. Click and complete the online claim which can be found below. You must download the completed printed form when you are done, sign in the appropriate places and send the claim and all paperwork pertaining to the claim to the state office:

Eastern Pennsylvania Youth Soccer
Insurance Claim
4070 Butler Pike-Suite 100
Plymouth Meeting, PA 19462

2. Paperwork required for Claim: The claim form 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 90 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 or send directly to Bollinger with the claim number attached.
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 Eastern Pennsylvania Youth Soccer office.

Bollinger Insurance Claim Form

Bollinger Insurance Claim Form
(Complete the online form, print it out and send to Eastern Pennsylvania Youth Soccer)

Medical Insurance Coverage

Bollinger General Insurance Information

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 Eastern Pennsylvania Youth Soccer directly. If your club/league purchased the coverage, then there is a $250 deductible (this $250 is not applied towards your primary deductile, you will have $250 deducted from the amount you are requesting for a refund). You should check with your organization before completing the paperwork for a claim.

The cost of the medical insurance is $25 per team.
Eastern Pennsylvania Youth Soccer
4070 Butler Pike, Suite 100
Plymouth Meeting, PA 19462
P: 610.238.9966
F: 610.238.9933
©2018 Eastern Pennsylvania Youth Soccer Association. All rights reserved.
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