The medical coverage is an optional coverage and not every Club or league has chosen to participate in the medical coverage offered by EPYSA. If your Club purchased the coverage, then there is a $100.00 deductible (this $100.00 is not applied towards your primary deductible, you will have $100.00 deducted from the amount you are requesting for refund.) Some clubs have their own insurance and/or have signed a waiver. You should check with your Club before completing the paperwork for a claim. The cost of the medical insurance is $27.50 per team. If your Club chose not to purchase the insurance, then a team may purchase the insurance on their own through EPYSA.
Please complete the two claim forms and return along with your itemized bills, explanation of benefits of benefits (EOBs) from your primary insurance carrier, and any cancelled checks for bills you have paid relating to this injury, to EPYSA, 2 Village Rd., Suite #3, Horsham, PA 19044.
The claim forms should be submitted within 30 days of the date of the injury if possible.
You may send the claim forms as soon as possible and then submit the EOBs at a later date.
If you do not have primary insurance coverage, please submit a letter to EPYSA stating that you did not have medical insurance at the time of the injury. This letter must be notarized and must accompany all itemized bills.
If you have any questions contact Kate at the EPYSA office at 1-800-562-7485.
EPYSA Medical Claim Form (PDF file)
Bollinger Insurance Claim Form (PDF file)
EPYSA Proof of Liability Insurance Form
In the event owners or operators of game and/or practice facilities require proof of liability insurance before allowing member organizations to use those facilities, you can request a certificate from EPYSA by completing the request form and returning it to EPYSA, 2 Village Rd., Suite #3, Horsham, PA 19044.
EPYSA will NOT issue certificates without a written request.
EPYSA Proof of Liability Insurance Request Form (PDF file)
EPYSA Insurance Verification Form
In the event a tournament requires a team to submit proof of insurance complete you can request verification by completing the request form and returning it to EPYSA, 2 Village Rd., Suite #3, Horsham, PA 19044.
EPYSA will NOT issue certificates without a written request.
EPYSA Insurance Verification Form (PDF file)
