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When an Incident Happens

When an Accident/Incident Happens

In the event of an Injury, Incident, or Property Damage, some paperwork obviously is necessary to ensure proper documentation and that insurance coverage, if needed, is obtained.

Currently the Safety Director is:    Joel Lautenschleger

                                                                           [email protected]  

                                                                            [email protected]     


1)      Incident Report Form

The AYSO Incident Report Form must be completed and returned to the Regional Safety Director and/or the Regional Commissioner and can be completed by the Referee or the Coach of a player involved.  This form is available on our Region 1422 web site.  Look under Safety, then Links:

The Incident Report Form will need to be completed and returned to the Regional Commissioner, Safety Director, or Tournament Director. Below is a list of possible situations that would require an Incident/Accident Report form.

o   Injury/Concussion      

o   Threats of Bodily harm

o   Fighting

o   Property Damage

o   Hospitalization

o   Law Enforcement

o   Lawsuit


2) Claim Form     

The claim form used to file a medical claim can  be printed out from our Region 1422 web site. Look under Safety, then Ljnks.

The claim form must be fully completed by a parent or responsible party and submitted within 90 days from the date of injury. Incomplete claim forms are one of the most frequent reasons why claim payments are delayed. The AYSO insurance carrier assumes a second place position after your own medical insurance and there is a deductible that varies but usually it is around $1000.00


The claim form must be signed by the Regional Commissioner and the Safety

Director.  Only one claim form for each accident needs to be submitted.  Once

completed, make a photocopy for your records and mail to the address shown on

the form.

Do not assume that anyone else will mail this claim form for you.


Present Insurance Carrier:          Willis Insurance Services of Georgia, Inc.  

(Effective 7-1-2018)             Concourse Corporate Center Five

                                                                18th Floor Atlanta, Georgia 30328



3)      Participation Release Form

Participation Release Forms are also made available to all coaches and can also                                     

be printed out from our Region 1422 web site.  Look under Safety,  then

Links.  These forms must be completed and returned to the Safety Director for seriously injured participants as soon as possible after their return to play. 

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Laguna Hills, California 92653

Email Us: [email protected]
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