All players registered with the Maryland State Soccer Association are covered under the US Adult Soccer Special Risk Accident policy while participating in any sanctioned event. If treatment is necessary for an injury sustained during a league game, practice or affiliated tournament, the player is encouraged to file a claim using the instructions below. Unaffiliated activities that are not under the organization of an MSSA/USASA member are not covered.
Note: This coverage is EXCESS of other insurance. Please be sure to submit other insurance information (if available) when requested.
We are now using a new online claim format. The claim can be found in English or Spanish. Go to the following link:
USASA Special Claim Form for Risk Accident
- Fill in each text box
- On text boxes that ask for a date, the year may be changed by clicking the year on the calendar at the top. Click twice.
- If covered by more than one health insurance play, please include the additional policies (+Add Another Plan)
- Under Name and Type of Event, indicate if league match including the teams scheduled or if during training and the name of your team
- Type Maryland for State Association and type in your League for Region.
- For coach or official, list name of team coach or manager
Do not delay submitting this form. It must be submitted within 90 days from the date of the accident or benefits may be denied due to untimely filing.
The form will be reviewed by the State Association Verification Officer, which includes coordination with the respective league. It will then be sent to US Adult Soccer. US Adult Soccer will forward the claim to AG Administrators for processing. AG will contact the claimant for further information/documents.
If you have medical coverage under another policy, those bills must be submitted to your primary insurer first. When submitting your claim under this program, you will asked to provide a copy of your primary insurer’s Explanation of Benefits statement (EOB). IF YOU HAVE OTHER INSURANCE, YOUR CLAIM CANNOT BE PROCESSED BY AG Administrators WITHOUT YOUR PRIMARY CARRIER’S EOB.
Once submitted, the claimant will receive a confirmation email that the completed form is received along with a claim number.
If there are any questions concerning these procedures, email us at MSSAFalcone@msn.com.