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Please note a copy of the current player pass for travel, and a copy of your insurance card must be sent along with the claim form.

There is a $1000.00 deductible associated with this policy.

To be used for injuries occurring after 9/1/19

Medical Claim form for the 2019-2020 seasonal year

You will need the Acrobat reader to display the form.

You can also obtain an Accident/Medical claim from the NJYS Office.

  1. Complete ALL questions on the Youth Soccer Accident Claim Form.
  2. Have the coach or another local official that witnessed the accident sign Section III (COACH OR LOCAL OFFICIAL VERIFICATION).
  4. File this new report of claim within 90 days of the date of accident or as soon thereafter as is reasonably possible.
  5. If you have other insurance, submit your itemized bills to the other carrier first. You will receive a payment Explanation of Benefit worksheet (EOB) from your other carrier. Do NOT wait until your other carrier has processed all your bills before filing a Youth Soccer Accident Claim Form.
  6. You may attach itemized bills and your other carrier's EOBs that are ready at the time of submitting this Claim Form.
  7. Send the Claim Form to your State Association for verification and authorized state signature. DO NOT SEND THE CLAIM FORM DIRECTLY TO PULLEN INSURANCE SERVICES. Please email to insurance@NJYouthSoccer.com
  8. Upon receipt of the claim form from your state association, the insurance company will forward an acknowledgment form advising you of receipt of your claim. All future correspondence concerning your claim should be directed to K&K Insurance at the address and phone number listed on your acknowledgment.

Send the completed form to the NJYS office within 90 days of the injury. Do not wait for bills from your medical service providers or payments made by your insurance carrier.

Please include a copy of the referee report for the match the injury occurred if available.

IMMEDIATELY submit a claim for all medical expenses to the Company that administers your own personal or group insurance or healthcare plan (including Major Medical coverage). If you have coverage through an HMO or similar facility, you must use that facility first or the claim will not be covered under this policy.

After your other insurance or healthcare plan has paid the medical expenses up to the policy limits, attach any unpaid bills and copies of payments made by your insurance company (Explanation of Benefits) and mail to K & K Insurance Group Inc. at the address shown below.

All subsequent bills should be sent to K&K Insurance Group, Inc as you receive them. Please write the claimant's name and date of accident on all subsequent bills. A new claim form is not necessary. Bills that are sent to the NJYS office will only delay payment to your service provider. Once the claim has been filed with NJYS, any bills should be submitted directly to:

K&K Insurance Group Inc.

Claims Department
PO Box 2338
Fort Wayne, Indiana 46801-2338