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.
To file a claim, open the following link:
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Instructions to File Your Claim
- Fill in each text box
- Under Name and Type of Event, indicate if league match including the teams scheduled or if during training and the name of your team
- For coach or official, type name of team coach or manager
Save the PDF form and email it to MSSAFalcone@msn.com. Do not send to your league, MSSA will verify with league official. 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.
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.