ࡱ> MOL%` ]bjbj"x"x `X@@]  wwwdffffff$hU"wa444 d4d444 qn7 4X 04(44$wZ@44Ewww* www Connecticut Junior Soccer Association NOTIFICATION OF ACCIDENT (Print or Type Only) Name of Insured (Injured Party) _______________________________________________ Phone # _____________________ Address of Insured ____________________________________________________________________________________________ Player _____ Coach _____ Assistant Coach _____ Administrator _____ Club Referee _____ Date of Accident _________________________ Location of Accident _______________________________________________ Description of Accident ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Description of Injury ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Is the CJSA your primary insurance carrier? Yes _____ No _____ If you have primary insurance, you must submit all claims to that carrier before submitting your bills to CJSA. After all payments have been made, submit the completed claim form along with the itemized statements from each healthcare provider and the payment explanation worksheets to your Club President, District Vice President or Registrar. If the claim is for an injury at an approved CJSA Commercial Indoor Facility, the Owner/Manager must sign the verification. VERIFICATION OF INJURED PARTYS REGISTRATION, CLUB AFFILIATION AND ACCIDENT I, _______________________________________, as President (or Indoor Owner/Manager) certify that on the date of the accident listed above, ___________________________________________________ was registered with our club (facility). I understand that proof of registration may be requested if needed. Club (Facility) Name _______________________________________________ Club Presidents (Facility) Name and Phone # _______________________________________________________________________ _______________________________________________________ Date Signed: ________________________________ (Club Presidents (Facility Owner/Manager) Signature) _______________________________________________________ Date Signed: ________________________________ (District Vice President or Registrar Signature) AFTER THE FORM HAS BEEN SIGNED BY ALL APPROPRIATE PARTIES, IT IS TO BE SENT TO: 11 Executive Drive Farmington, CT 06032 (860)676-1161 'A'9:NO\]hLyh5 hLy5hLyhLy5 h5hjhU '(AVWX8 9   r s * + Q R $a$] ij)*<=':O]$a$gdLydh(/ =!"#$% n.<_߻1OjQpe PNG  IHDRK-OegAMA IDATxܼweu';_ P @XD+ڕe\%k-{k˲VVeT*Z(J)Ѣ$ #H !  &/?nwb`tTW׼Ns.13^Kk B}ZRJ){/t{-H7wKBeiiwBTUBȲsUU%ImyYTw+ӎ[0}gUUZ|ФoH{53;1sliBF4Bi~6(7ivs!!'СC~w=˲x$bGpG 49PY-BGZ8pSh4Z[[;{<ω&b؅?J{󞿗 mwBm{~fgg,SJ۷ë/˗<;v*ӫ,7o$"jӆGɟu]:55駟޷o߻'|///+ZŬa_i@5E"9Z ^1KzP(GC?sNk;:`fA5Ug\zg=j=I2%bD^4XE'D!@ !$I f0k!$j` n$'lCJ`ƀbVeA(ֽKJ>*-x@9 ^顠A{7ID1*Ix>g4B(sD5#1,' ny[f'zw#ɤ( f.2˲7F%r9t:nAF{ʲNS I9JXЙӗv:.'zmIȾ^\sΜ.|;mGĒW'j0$A8F!5!ܙjfӬGT/3'D goC7wlUn5A K+ mI꧞>ww$= &b#uRicȈ ci@]8?w?/OFx<~sssKKKQ}$/\}̋ϟ|СCywʻz2)m"􁙈lj?ȣ{؊)AZmٽ׊0]Y{;~Rd2kQAxc-?yΣMn 28Jv?wIӴ Ւ,%ҟ?ME )B w-Y6 (BfF߻wY֧_:;̾{`҅SYw~w>Ϝ>}z8~?s?#[Owy[[m"7VT:M2Aw㧀c)Ccd `gtMw/-y≛6J)R0uVs =:$N)2}* 8Ll<K)1BkM$ˏ ~g'zn4bM!zmsL>XimocIT9)׆lpgeY~8zhK49r~JfzwuC=W$b0Y%gϬگߧ[-dT6 @/I| j4w78˴B^,sCa(2XT#>{~G6Z+@RU5 feO6/=y둽i 5AIW%~C-3 MM,K׼Nj и*iE袓 _/EIV>sҪ^-xٳRʍoo閪j.?C?@ eYFSEST 7~O8ͻU7zfǍ$ Ĉ@6H.:fN/OU)ZR'6?20TG_Pd24M-Ƀ ^H)zd F*6!p lm=:oEc JsbF g^8ս83{/_J4MӲ,;!\xߛ-ruuSO;$ 2ݞ~w&4=P~9dc 6IVo T]ׯ~WQai\yGWJ6B8} ?s(PBvBbYECpͨ*dR׵'ѯ_ݳg/jy}]WIS^a.YytD_B,>8Pc)̋daܠ,m/,,HaܹsƘi?#?wsmu2Y<|pU5w'QIׄN!x#V'3*@ CYs-hߤx~~np躅{QLb;qwrRH>Jc'?jp@TBl#kPR^5M.bɱ+@q1 ̿vV+2Sic oz}A? 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