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How to file the Special Risk Accident Claim Form


 

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. Please read the form carefully to avoid delays in the processing of your claim.  It is the responsibility of the claimant (injured participant) to submit all itemized provider bills and explanation of benefits with their claim.  If this information is not readily available at the time of submitting the claim form, it may be submitted later. 
Download SPECIAL RISK ACCIDENT CLAIM FORM
1. You have been provided with a claim form that is designed specifically for US Adult Soccer. Please use only this form. Do not delay submitting this form.  It must be received with or without attachments, within 90 days from the date of the accident or benefits may be denied due to untimely filing.
2. Part A must be fully completed by the participant or his/her legal guardian. It is requested that the form be completed using Adobe Reader.  The form may be saved with all of its contents.
3. Participant must sign page 3 of the form, titled Authorization.
4. The bottom of page 2 of the form needs to be verified by the coach, manager or referee who witnessed the injury. The League Verification Officer must sign the form to verify that the player was injured at a sanctioned event.
5. Once all the signatures are in place, mail the form to the following:
Maryland State Soccer Association
2305 Drexel Street
Hyattsville, MD 20783-2718
Submit along with the claims form all itemized insurance billing forms.  These forms are available from your health care provider and include the patient’s name, condition (diagnosis), type treatment and date the expenses(s) was/were incurred. “Balance due” statements are not acceptable.  
6. The form will be reviewed by the State Association Verification Officer and then sent to US Adult Soccer, who then send the documents to K&K Insurance  for Processing.
7. If you have medical coverage under another policy you must submit the bills to your primary insurer first and submit a copy of your primary insurer’s Explanation of Benefits statement (EOB) with your claim form.  IF YOU HAVE OTHER INSURANCE, YOUR CLAIM CANNOT BE PROCESSED BY K&K Insurance Group, Inc. / Specialty Benefits WITHOUT YOUR PRIMARY CARRIER’S EOB. 
 
8. Once the completed form is received by K&K Insurance Group, Inc/Specialty Benefits, you will receive a claims acknowledgement letter. 
9. AFTER you receive your Acknowledgement Letter, you may contact K&K Insurance Group, Inc./Specialty Benefits at 800-237-2917 Option 1.

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



Special instructions:

  • 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.


 
 

 

 
 

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