INCIDENT (ACCIDENT) REPORT: The AYSO Incident Report Form is used whenever there is a personal injury, damaged property, or threats of or actual physical violence surrounding an AYSO game, practice, event or property.
This form should be prepared by the Coach, AYSO Official, or other AYSO Volunteer. The form may also be prepared by a member of the regional staff such as the Regional Safety Director, or by Tournament or Event Staff Members.
AYSO VOLUNTEER:
1. Please advise the Regional Safety Director immediately, at djongbloed@gmail.com that an incident has occurred.
2. Download the
"Incident Report Form with Instructions."
3. Complete, sign and return the form to the Regional Safety Director at 733 Loma Vista St. Unit B, El Segundo, CA 90245.
4. If the incident occurred at a tournament, please provide a copy of the team's tournament application.
Please contact the Regional Safety Director at
djongbloed@gmail.com or 310-920-2941 with any questions.
SAI (Soccer Accident Insurance) CLAIMS
AYSO VOLUNTEERS: Please advise the Regional Safety Director at djongbloed@gmail.com of the incident asap.
PARENTS:
1. Please advise the Regional Safety Director of the incident immediately.
2. The Regional Safety Director will follow-up with the AYSO volunteer; however, if this is a personal injury please assist us by reminding your coach to submit an incident report
3. If you plan to submit a claim, please download the "SAI Claim Form with Instructions" as well as the "SAI Brochure" from
AYSO.ORG (click on "PARENTS") or
http://www.ayso.org/resources/insurance.aspx
(Be sure to click on the section for injuries after July 1, 2010)
4. Read all instructions very carefully, noting that all claims must be filed within 90 days and must include the required regional signatures.
5. Prior to mailing your claim, please make arrangements to obtain the signature of the Regional Commissioner AND THEN the signature of the Regional Safety Director. You may contact them at:
Mike Doherty, Regional Commissioner: ayso92rc@sbcglobal.net
Drew Jongbloed, Regional Safety Director:
djongbloed@gmail.com
6. All claims must be filed directly with the insurance company, NOT Region 92 nor the National Support and Training Center (NSTC). Mailing address is on the claim form.
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Please contact the Regional Safety Director with any additional questions at
djongbloed@gmail.com or 310-920-2941
