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Forms for Insurance


Explanation of Coverage:              /assets/112/6/nccoverages-2021-221.pdf


General Liability & Excess Liability

Participant Injury or Accident


Certificate of Insurance (COI)

Local NCYSA Member Associations may request a certificate of insurance (COI) for their locations used for training, scrimmages, games, and tournaments by following the instructions below.  This form should be filled out by the Local NCYSA Member Association’s president, executive director, field coordinator, or head registrar ONLY.  Forms filled out by any other person will not be approved.   


Expected turnaround time for a new submission is same day (2-6 hours) during normal weekday business hours.


COIs are only emailed to the one designated person at each Local NCYSA Member Association.   


For questions or to request a copy of an EXISTING COI, email


To Request a COI for a New or Missing Location:

  • Click this link:
  • Enter the Facility’s name and address, etc….
  • Choose your Association’s Name in the dropdown menu.
  • Enter the name of the person filling out the form.
  • Leave “Special Wording” and “Event Date” BLANK.  Only enter text under “Special Wording” when it is absolutely necessary.  Typing anything in this box requires extra review by the insurance company and will delay the COI being issued by a minimum of 24-48 hours.
  • Click the SUBMIT button at the bottom.
  • Repeat until all locations are entered.
  • Close your browser window when finished.


To File a Supplemental Injury Report:

Submit by completing the form at:

Once completed, both you and NC Youth Soccer Association (NCYSA) will receive an email indicating that a First Notice of Loss (FNOL) has been submitted/received. This will prompt NCYSA to go in and review the claim.  Once they have reviewed and have approved, you will receive an email notifying you that it has moved from a First Notice of Loss (FNOL) to a claim and will provide you with some additional instructions and contact information.   The broker (Players Health) will submit the claim form to the insurance carrier’s Third-Party Administrator (TPA) for processing. You should receive a letter of acknowledgement within 16 business days from the date that your report has been approved by the state soccer association. 

Please note the following:

  • The claim acknowledgement letter is sent via email. You will want to watch your spam/junk mail folders closely.
  • The FNOL & Claim numbers that you may receive from the Players Health claims portal are just internal tracking numbers and are not used by the insurance carrier/TPA.

To complete the filing process, you will need to collect the following information:

  • Itemized Bills from providers (must include procedure and diagnosis codes). These forms are often referred to as UB-04 or HCFA 1500. You will need to request these from your provider as payment cannot be made from the balance due statements that are generally automatically mailed out to you.
  • Copies of your primary insurance Explanation of Benefits (EOBs). These will either be mailed directly to you from your insurance provider or will be available online to you on your insurance provider's website.
  • If you have them available, you can also submit paid receipts showing what you have already paid out of pocket for this injury.

You will need to submit all of these items to the Third-Party Administrator (TPA) once you have received your claim acknowledgement letter via email from them. Please note that it is STRONGLY recommended that you keep copies of all items submitted for your records – DON’T send your only copy. We would certainly hate it if something were unexpectedly lost in the mail.

Also, please note that your injury claim will be processed per the policy provisions. That means that you will be responsible for a deductible under this policy. 

We appreciate your patience as your claim works its way through this process. Please let us know if there is anything we can assist you with.