YOUTH SOCCER ACCIDENT PROOF OF LOSS

Eastern New York Youth Soccer Association
TO BE COMPLETED BY CLAIMANT
NAME OF CLAIMANT    (Last Name)                                          (First Name)                                (Middle Name)
ADDRESS OF CLAIMANT    (Street)                        (City)                     (State)                       (Zip code)
SOCIAL SECURITY NUMBER DATE OF BIRTH SEX Male      Female
TELEPHONE NUMBER
(           )		 OCCUPATION
DATE & TIME OF ACCIDENT
 ACCIDENT DUE TO EMPLOYMENT?  Yes    No
NATURE OF INJURY
FOR ACCIDENTAL INJURIES PLEASE COMPLETE THE FOLLOWING:
A.  DESCRIBE ACTIVITY ENGAGED IN AT TIME OF ACCIDENT
__________________________________________________________________

B.  PLACE OF ACCIDENT (BE SPECIFIC)
__________________________________________________________________

C.  DESCRIBE HOW ACCIDENT HAPPENED
__________________________________________________________________

MEDICAL AUTHORIZATION

I hereby authorize the release of any medical or other information necessary to process this claim, including all data covering this and/or previous confinements and/or disability. Please sign here:______________________      _________
                          Claimant (if adult) or Parent/ Guardian               Date

PAYMENT AUTHORIZATION

I hereby authorize payments of benefits directly to the providers rendering services. Please sign here:_______________________      _________
                           Claimant (if adult) or Parent/ Guardian               Date

___________________________________________________________

STATEMENT OF OTHER INSURANCE

1.   Name and Address of Claimants Employer:  (If a minor, complete # 2 & 3)
2.   Father's Name or Guardian: Occupation: Name and Address of His Employer: Phone #:
3.   Mother's Name or Guardian: Occupation: Name and Address of Her Employer: Phone #:
4.  Do you have a Group, Personal Healthcare or Medical plan?    Yes        No

Name of your Health Care Provider

Address
. .
. .
I hereby certify, swear and affirm that the information given above is true and accurate.   I fully understand that any willful misrepresentation made by me in an attempt to collect benefits under this policy constitutes fraud and is punishable by law.
Signature___________________________________________
                        Claimant (if Adult) or Parent/Guardian		 Date________________
TO BE COMPLETED BY POLICYHOLDER / ADMINISTRATOR
POLICY NUMBER
SRG9028872		 CLAIM OF GROUP POLICYHOLDER
Eastern New York Soccer Association
ADDRESS OF POLICYHOLDER                   (Street)                     (City)                       (State)                        (Zip Code)
                                        49 Front Street         Rockville Center        NY                      11570
TELEPHONE NUMBER
(516) 766-0849
IF ACCIDENT OCCURRED DURING AN ACTIVITY SPONSORED OR SUPERVISED BY YOUR ORGANIZATION, DESCRIBE ACTIVITY, HOW ACCIDENT OCCURRED, AND SPECIFY DATE OF OCCURRENCE.

 
REMARKS:

 

 

I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT.
AUTHORIZED SIGNATURE:___________________________		 TITLE DATE

 

INSTRUCTIONS FOR FILING AN ACCIDENT CLAIM:

1.  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.

2.  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) to this claim form and mail to the address shown below.

3.  Please check and make sure that:

  1. An Official or Administrator of the Policyholder has completed his/her section of the claim form.
  2. You have completed and signed the Parent/Guardian or Insured’s Statement of other Insurance.
  3. The Medical Records Authorization MUST be signed and dated. If you want payments to be sent directly to your doctor or healthcare provider, sign the Payment Authorization Section.
  4. You have attached all unpaid bills to this form.
  5. You have attached any Explanation of Benefits forms that you have received from your Primary insurance carrier or other healthcare plan.
  6. You have completed the front of this form.

4. Subsequent bills should be sent in as you receive them. Please write the claimant’s name, policy number and date of accident on all subsequent bills. A new claim form is not necessary.

If you need further information, call Bollinger at 800-526-1379. Our Accident Claims fax number is 973-921-2876.

PLAN ADMINISTRATOR:
BOLLINGER, INC.
P.O. BOX 390, SHORT HILLS, NJ 07078-0857
TELEPHONE 1-800-526-1379

 

 MAIL THIS FORM AND ALL ITEMIZED BILLS TO:
Eastern New York Soccer Association, Inc.
53 N. Park Avenue, Suite 201
Rockville Centre, NY 11570
Telephone (516) 766-0849  Fax (516) 678-7411