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Insurance Information for Adult League Players - KSA provides injury insurance on all registered LYSA adult players. To make a claim, please read through the entire list of directions below.

Note: if an injury occurs during a LYSA match, please verify with the center referee that the injury will be reported on the Referee Game Report. Only injuries that are officially recorded are covered by the USASA Player insurance policy.

 

  1. Read Plan Summary for benefit information, link is found below.
  2. Complete all three pages of the Accident Claim Form, link found below. This is a form that you can write on and then print for your signature.  It is very important to complete all sections, and sign in the correct places.
  3. Contact Lois Stephens, LYSA Registrar  ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ), for verification of your registration.
  4. The referee report from the game in which you were injured is required, and is sent under separate cover.  Contact John Waizenhofer, league referee assignor ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ), to ensure this was completed and sent to KSA.
  5. A league official will need to sign off on the entire package before it's submitted. Please contact Allen Sharon,  the Adult League Director, at This e-mail address is being protected from spambots. You need JavaScript enabled to view it to arrange for this. 
  6. Once all of the above steps is complete, you may email the documents to

    eppolley@aol.com 

     or mail your claim to: 

Peggy Polley, KSA President  

10809 Oreland Mill Road 

Louisville, KY 40229

 

Forms:

Accident Claim Form

Plan Summary

Claim Filing Instructions

 

 


If you have questions, feel free to email me (Tracey McGaughey) at This e-mail address is being protected from spambots. You need JavaScript enabled to view it or call 859-223-5632.

 

OTHER FORMS:

 

W9 Federal Form   W-9 form must be filled out by referees, paid coaches, contract labor.

 

 

 

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