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INSURANCE COVERAGE AND FORMS

As of September 1st, 2018, K & K Insurance Group, Inc. is proud to be the official insurance program administrator for Iowa Soccer Association, Nebraska State Soccer Association and Kansas Youth Soccer. 

 

Youth Soccer-Related Insurance Information

Report an Incident and Certificate:

  • To report an incident, fill out the Incident Report Form and email or mail to Phil Gomez, Director of Membership.
  • To request a "Certificate of Insurance" see bottom of page for instructions.

 

Claim Procedures
In the event of injury requiring medical treatment, you should:

  • Fully complete a claim form verified by a witness and submit it to Kansas Youth Soccer for verification
  • Notice of claims must be filed within 90 days from the date of injury.


Youth Soccer Accident Medical coverage is provided on an "excess" basis.  Therefore, charges must first be submitted to any other medical insurance carrier available to the participant. 

 

 

TO REPORT AN INCIDENT 

 

Click the link below to fill out your form.

Pullen Incident Report Form (Type In Version)

Pullen Incident Report Form (Write In Version)

 

Once you completed the Pullen Incident Report Form please mail or email to Kansas State Youth 

 

Phillip Gomez
Director of Membership & Marketing

KANSAS STATE YOUTH SOCCER ASSOCIATION
10529 South Warwick St. | Olathe, KS 66061

pgomez@kansasyouthsoccer.org
913-782-6434 x 203
KSYSA Director Shield USYS Primary Vert Small Email

 


 

CERTIFICATES OF INSURANCE - FOR TEAMS ONLY

 

Current certificates of insurance are effective from September to August of each year for registered affiliate members.  Certificates of insurance for the next seasonal year will be dated as such and should be available by the last week of August once ESIX has received the insurance information from the underwriters and coverage is bound with the state association.

 

If you are a KSYSA League Administrator, to submit a request for certificate of insurance please be sure you have the information below gathered together and submit your request using the google doc form link below.

 

Certificate of Insurance Request Form

 

Name of Affiliate Member League/Club

Name of League Administrator Making Request

Name of Location for Certificate (i.e., Swarner Park, USD 259)

Complete Address of Location (Street Address, City, State, Zip Code)

 

This email request should only be completed by a League Administrator, not by parents or coaches.

 

 

If you have not received the requested insurance certificate within 48 business hours, please contact us at

 

Kelly Morgan

Executive Assistant 

KANSAS STATE YOUTH SOCCER ASSOCIATION
10529 South Warwick St. | Olathe, KS 66061

kmorgan@kansasyouthsoccer.org
913-782-6434 x 202
KSYSA Executive Assistant Shield USYS Primary Vert Small Email

 

 
 
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