2005/2006 Insurance Summary English
2005/2006 Insurance Summary Spanish
I. ACCIDENT INSURANCE PROGRAM GENERAL INFORMATION:
A. Who is covered?
All registered members, teams and leagues of the California Youth Soccer Association,
Inc.
This includes registered team members, employees, coaches, officials, managers, referees and volunteers of the teams,
leagues or of the Association.
B.
When are they covered?
The above participants are covered during sponsored and supervised activities of the CYSA, such as games, practices,
tournaments and other sponsored activities. In addition,
excess accident insurance is provided for injuries sustained while
traveling as a team directly to and from CYSA
sanctioned activity and traveling under the direct and immediate supervision
of a team official.
Important note: CYSA’s liability policy provides Hired and NonOwned auto liability coverage but only for
travel on the official business of CYSA.
II. ACCIDENT POLICY BENEFITS:
A. Limits:
|
Accident Medical Expense Benefit: |
$300,000. |
|
Accidental Death Benefit: |
$10,000. |
|
Accidental Dismemberment Benefit: |
$30,000. |
|
Deductible per claim: |
$250. |
|
Benefit period: |
156 weeks |
Full Excess Coverage*
*This is a full Excess policy. The benefits are payable in excess of any other Health Care Plan, (as defined
in the policy) regardless of any Coordination of Benefits provision contained in such Health Care Plan.
The medical expenses must be incurred within 156 weeks (3 years) of the date of injury and be reported within 90 days
of the day of injury.
A deductible of $250.00 will apply for each covered accident.
Claims will be paid on a Usual and
Customary basis.
B.
What is not covered? Notable exclusions under the accident policy are:
Selfinflicted injuries; Illness; Hernia; Preexisting conditions;
Charges which the Covered Person would not have to pay if he did not
have insurance;
Travel in or upon, any two or three wheeled motor vehicle or any offroad motorized vehicle or snowmobile not requiring
licensing as a motor vehicle;
That part of medical expense payable by any automobile insurance policy without regard to fault;
Practice or play in any intercollegiate sports activity;
Eyeglasses, contact lenses, hearing aids, or examinations or prescriptions therefore;
Any loss
which is covered by state or federal worker’s compensation, employer’s liability, or occupational disease
law;
Dental care or treatment other than care of sound, natural teeth and gums;
and intoxication.
III. HOW TO FILE AN ACCIDENT CLAIM:
In the event of an injury requiring medical treatment, you should:
A.
Obtain an Accident Claim form from the State Association Office or your league office.
B.
Complete the Claim Form and include copies of all itemized bills.
C. 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 form from your other Health Care Provider with this claim form.
D.
After you have completed the claim form, the bottom portion marked “Verification from a Team Manager
or
Team Representative”
must be filled out and authorized by the State Association.
The State Association will verify the information and forward the claims on to Bollinger,
the plan administrator, for processing and payment.
IV. UNDERWRITING INSURANCE COMPANY:
This accident policy is underwritten by:
Philadelphia
Insurance Company
Policy #: PHPK135475 Effective: 9105 to 9106
*Please visit
for additional insurance information.
V.
SUMMARY OF LIABILITY COVERAGES:
A. Insured:
California Youth Soccer Association, Inc.
And Its Registered Member Leagues, Clubs and Teams
1040 Serpentine Lane, Suite 201
Pleasanton, CA 94566
B. Effective:
September 1, 2005 to September 1, 2006
|
C.
Liability Limits: |
$5,000,000 |
Aggregate per location |
|
|
$1,000,000 |
Per Occurrence
|
|
|
$1,000,000 |
Participants’
Legal Liability |
|
|
$2,000,000 |
Product/Comp Ops Aggregate |
|
|
$1,000,000 |
Personal/Advertising Injury Limit |
|
|
$100,000 |
Fire Legal
|
|
|
$5,000 |
Medical Payments (to nonparticipants) |
 |
Nonowned/Hired Auto – Official Business of Insured Only |
|
No exclusion for Sexual Abuse & Molestation
Includes Host Liquor Liability |
|
Standard ISO 1996 CGL exclusions
|
D.
Liability Carrier:
Philadelphia Insurance Company,
E. Liability Policy Number: PST2546B
F.
For Certificates of Insurance, please contact the CYSA
State Office:
VI. GENERAL PROGRAM INFORMATION:
B. License:
Bollinger’s California License #: 0274666
This summary is intended as a brief description of coverage offered under this policy.
For a full description of the
policy coverage, conditions and exclusions, please refer to the actual policy
