Field Certificates of Insurance
A Field Certificate of Insurance (COI), or proof of liability coverage, is usually required by property owners such as school districts, city recreations departments, and private businesses before they issue a “Use Permit” to any organization requesting permission to use their fields or facilities.
To download and fill out a Field Certificate of Insurance, click here.
If you have further questions, please contact either:
- Brenda Schornak – USI Insurance Services | email@example.com
- Ryan Douglas – USI Insurance Services | firstname.lastname@example.org
- Shalom Suniula – USI Insurance Services | email@example.com
- Cal South Member Services | firstname.lastname@example.org
Other Youth Insurance Info:
Youth Program Insurance Snapshot – 2021-2022
Camps & Clinics
Camps & Clinics Non-Registered Youth Soccer Accident Claim Form 2021-2022
Formulario de Reclamo de Seguro Por Accidentes Ocurridos en Clinicas y Campamentos No Registrados 2021-2022
2020 Year (Injuries occurring between January 1, 2020 – December 31, 2020)
USASA 2020 Claims Filing Instructions Accident Policy
USASA 2020 Spanish Claims Filing Instructions Accident Policy
25k Player Insurance Coverage Request Form
USASA 2020 SPANISH ACCIDENT CLAIM Form AG
USASA 2020 ACCIDENT CLAIM Form AG
2021 Year (Injuries occurring between January 1, 2021 – December 31, 2021)
USASA Accident Claim Form
Formulario de Reclamación por Accidente de USASA
USASA 2021 General Liability Summary Updated 2021-05-21
Resumen del Seguro de Responsabilidad de USASA
USASA Accident Plan Limitations and Exclusions
Limitaciones y Exclusiones del Plan de Accidentes de USASA
Additional Accident Medical Expense Benefit Available for purchase by Adult Leagues
USASA 5k Policy Summary Updated 2021-05-27
USASA 25k Policy Summary Updated 2021-05-21
USASA 25k Player Insurance Coverage Request Updated 2021-05-27
What is the process for filing an SAI/PAI claim?
The process begins by completing the Adult First Report of Injury Form. The form can be downloaded below under Forms and Downloads. Once a completed form is received and verified by Cal South, the injured participant involvement will be sent to USASA-CHARTIS Claims Insurance for processing.
Is there a deadline and a limitation to filing an SAI/PAI insurance claim?
Yes, the first notice to the insurance carrier must be within 90 days of a covered accident. Excess benefits are paid after a $400.00 deductible is satisfied by the participant. Co-pays will count toward the deductible.
How do we obtain our general liability certificates of Insurance for our fields?
This is a tremendous Member Benefit provided by Cal South to our Member Leagues and teams as part of our insurance program. You can request your certificate by completing the Certificate of Insurance Request Form (See Forms and Downloads below). Complete this form and forward to email@example.com.
What if the facility requesting a Certificate of Insurance will not accept the standard certificate?
Please contact Cal South for assistance at 714-451-1500 or email at firstname.lastname@example.org. Please forward us any specific language or facility requirements along with your Certificate of Insurance Request Form.
In order to initiate the Cal South Insurance Claim Process, please follow the steps below:
STEP ONE: Download and fill out the appropriate Insurance Claim Questionnaire:
2021-2022 season (Injuries occurring July 1, 2021 – June 30, 2022)
2021-2022 Youth Insurance Claim Form
2021-2022 Formulario de Reclamo de Seguro por Accidente
2020-2021 season (Injuries occurring July 1, 2020 – June 30, 2021)
2020-2021 Youth Insurance Claim Form
2020-2021 Formulario de Reclamo de Seguro por Accidente
Upon receipt and verification that this is for a Cal South Registered Player, and that the incident took place at a Sanctioned Cal South event, the Cal South Corporate Office will forward the necessary forms to initiate the official claims process.
STEP TWO: Complete and file the actual claim forms. Information on how to file is included on each form.
STEP THREE: Upon receipt of the forms by our insurance carrier, they will finalize the claims process and notify you accordingly. A valid Social Security Number, Visa, or Green Card is mandatory for the claim process to begin. We recommend you keep a copy of the paperwork you send to the TPA for claim filing.
P.O. Box 25987
Shawnee Mission, KS 66225-5987
P: (800) 551-0824
F: (866) 893-8574