How to file the Special Risk Accident Claim Form
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.
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Instructions to File Your Claim
Go to the following link to file your claim:
- Fill in each text box highlighted in yellow
- In the Team section, select Maryland State Soccer Association under Association
- In the League or Tournament Name, select Type in Manually and type in your league
- If you have any bills or insurance documents, drop PDF copy in the attachments box
- Click Sign Here and use your computer mouse or finger to write signature
- Form cannot be submitted if required fields are not complete
The form will be reviewed by the State Association Verification Officer, which includes coordination with the respective league. Oncet verified, he the claim will be sent 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.