HOW TO FILE A SOCCER-RELATED INSURANCE CLAIM
The Louisiana Soccer Association (“LSA”) insurance plan is an excess medical plan. This means that benefits are provided only after all other insurance benefits are paid. These other insurance benefits may be through traditional insurance policy, the LaCHIP Plan (see link to the left) or by a HMO, PPO or other similar arrangement. Information about your primary coverage must be included on your Claim Form and all itemized bills must be submitted to your primary carrier first.
STEP 1 The Accident Medical Claim Form
Complete ALL questions on the Accident Medical Claim Form. Please note The Accident Medical Claim Form:
MUST be signed by a player’s Coach, Assistant Coach or Team Manager who is unrelated to the player
MUST be signed by the club Registrar.
MUST be filed with LSA within 90 days of the accident.
STEP 2 Incident Report
A player’s Coach, Assistant Coach or Team Manager who is unrelated to the player and who witnessed the incident during which the player received his/her injuries, MUST complete and submit an Incident Report.
STEP 3 Initial Medical Report
A report from the player’s physician and/or from the Hospital which treated the player’s Injuries must be submitted. The report MUST detail
Player’s Name, address and date of birth.
The date of the injury and date of the treatment provided.
An explanation or diagnosis of the injury or injuries suffered.
STEP 4 Claim Package Checklist
The Claims Package Checklist must be completed and signed. This Checklist shall be used by both the player submitting the Claim and by LSA to insure that all documentation has been completed and submitted to LSA.
STEP 5 Submit Claim Package
Send Claim Package including all supporting documentation directly to Louisiana Soccer Association.
DO NOT SEND THE CLAIM FORM DIRECTLY TO PULLEN INSURANCE SERVICES.
STEP 6 LSA Verification
LSA will verify the claim and that all supporting documentation has been submitted and will send your claim package to the Insurance Company. If the Claim Package is incomplete in any way, it will not be processed and will be returned to be completed.
STEP 7 Insurance Company Acknowledgment
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 the Insurance Company at the address and phone number listed on your acknowledgment. The insurance company may contact the injured player to request additional information after they receive Claim Package. Also, if any additional bills need to be submitted at a later date (after the initial submission of your claim) send them directly to the appropriate insurance company with the following information:
- Name of injured player
- Date of accident
- Name of state association – Louisiana Soccer Association