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Parent Injury Notification

Dave Amin, MD, FACEP
Region 10 AYSO Safety Director
36 Harbor Sight Drive Rolling Hills Estates, CA 90274
Phone contact at 310-755-4007 (cell) text or IM preferred
Dear Parents:

I have been notified your child was injured in an AYSO activity and required medical treatment. I hope they recover quickly from their injury.

Whenever medical treatment is required or your child cannot continue playing soccer please complete the “Notification of Injury” form. Call me or download the form from the National AYSO website

When your child is able to play, please complete the “Participation Release Form” and return it to me.

The new “Notification of Injury “ form replaces the “Soccer Accident Insurance Claim Form” (Bollinger, Inc.), “Soccer Accident Insurance Notification of Injury” (Maksin Management Corp.) and any older forms such as “Preliminary Accident Report Form,” “Request for Accident Reimbursement” form or “Injury Report” form that some coaches may still have. The new “Notification of Injury ” from will be the only form used to report an injury requiring medical treatment. It is used for reporting an injury and also for submitting a claim for insurance.

Please have Part A completed by the coach, referee or other AYSO official who witnessed the injury. Please complete Part B. Mail the completed form to me for signature. I will return the form to you to submit along with all itemized bills to Dianna Taormina, American National Life Insurance Company of Texas, AYSO Accident Claims, The Loomis Company, P.O. Box 13906, Reading, PA 19612.

Do not wait to receive all bills before filing a claim, simply forward additional bills and Explanation of Benefits Forms (EOB’s) to American National Life Insurance Company of Texas and write “AYSO” on each bill.

Please contact me as soon as possible if you have any questions or need assistance in completing the forms.

Dave Amin, MD, FACEP
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