AIG Personal Accident Claims Department

AIG Personal Accident Claims Department
This form can be used to Submit a Secondary Medical Insurance claim for both athletes and volunteers of TYFA as long as:
1. The location of the injury was an officially scheduled TYFA Event; and
2. The organization they belong to is a TYFA member in good standing; and
3. The athlete or volunteer is certified for the season the claim is being made for
If you have any questions before preseeding, send it to HelpDesk@tyfa.com
UNDERWRITTEN BY
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NAME OF GROUP
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POLICY NUMBER
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NAME OF LEAGUE
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TITLE
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TYFA REP
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PHONE
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AIG Personal Accident Claim
Select Claimant Type*

Athlete (3 to 15)Volunteer Trainee (14 to 17)Volunteer Adult

AIG Personal Accident Claim
Was Accident related to activity sponsored by TYFA?*

YesNo
Date of Injury first treated?*

MonthDayYear
Date
Nature of Injury?*

0/50
Describe How and Where the Injury occurred*
Example: Tackled on the field of a football game.
Select Activity*
Select Sport*

AIG Personal Accident Claim
List Name, Address and Phone of other insurance company*

0/80
Policy Number*
Date*

MonthDayYear
Date
Authorize payment of medical benefits to the physician or supplier for service performed*

YesNo
Signature*

Clear
Should be Empty: