Procedures to File a Accident/Medical Insurance Claim

You can download a claim form by clicking [pdf] or [doc] [Updated September 23, 2009].  You can not use previous forms as they are obsolete and your claim will be returned to you.  You will need the Acrobat reader to display the form.  You can also obtain an Accident/Medical claim from the NJYS Office.

Complete Sections I, II, IV, V and VI.  NJYS must complete Section III.

• The first line of Section 1 is the player and is the same as the patient.
• Be sure to enter your team name and club name on Line 1 of Section 2
• For travel team players make a copy of the team roster and photocopy of the player pass.
• If your player is also registered with another US Soccer organization include a copy of your Accident/Medical claim form that you have submitted to that organization.

Please check and make sure that:

a) You have signed both the Statement of Certification and Authorization to Release Information on Page
    2, Section VI.  Your claim will be returned if these two sections are not signed

b) You have fully completed only Sections I and II on the front of claim form.

Send the completed form to the NJYS office within 90 days of the injury.  Do not wait for bills from you medical service providers or payments made by your insurance carrier.  Do not send the claim form directly to Bollinger. They will not accept a claim without the authorization of the NJYS Office.

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 Bollinger Insurance at the address shown below. 

All subsequent bills should be sent to Bollinger 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.  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:

Bollinger Sports Claims
PO Box 390
Short Hills, NJ 07078 

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This page last modified on October 27, 2009
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