Club Forms
Injury Report Form
To file an accident insurance claim, complete the applicable form and follow the instructions below:
- Complete and submit the appropriate claim form. (Claimant/parent/guardian)
- The claimant/parent is to send the applicable claim form only (do not include itemized bills or EOBs) to US Club Soccer for verification.
(click the Player Accident Claim link on the subsequent page, and follow instructions on this page)
Send via email to: insurancequestions@usclubsoccer.org, or
Send via postal mail to: Insurance Claims | US Club Soccer | 716 8th Ave N | Myrtle Beach, SC 29577
Complete and submit the Insurance Claim Verification Form (#R011). (Registered US Club Soccer staff member/coach)
In addition, a coach, team manager/ captain (if adult) or other registered staff member who was present at the time of the incident is to complete and submit the Insurance Claim Verification Form (#R011) when a parent submits an accident insurance claim for one of his or her players. This information provides verification of the player’s injury prior to submitting the claim to the insurance company for review.
After US Club Soccer approval, follow instructions received from the claims administrator. Once steps 1 and 2 have been completed, and the documents verified and approved by US Club Soccer, the claimant will receive a signed copy of the claim form along with instructions for submitting the itemized bills and EOBs for claim processing. Do not send, and do not have your provider send, these documents to US Club Soccer.
Other Claim Eligibility Requirements:
- Treatment(s) must be medically necessary.
- The first treatment must occur within 90 days of the date of injury.
- All treatment(s) must occur within 52 weeks of date of injury.
- The completed claim form (#1 above), as well as the Insurance Claim Verification Form (#2 above), must be properly completed and submitted to US Club Soccer within 30 days of injury, or as soon as reasonably possible, but no later than 52 weeks after the date of injury.
Contacts:
- Prior to submission or US Club Soccer approval of your claim, please contact insurancequestions@usclubsoccer.org.
- After US Club Soccer approval of a youth membership claim for an injury sustained through December 31, 2015, contact RPS Programs Bollinger Sports & Leisure.
- After US Club Soccer approval of a youth membership claim for an injury sustained in 2016, contact A-G Administrators at claims@agadm.com or (610) 933-0800.
- After US Club Soccer approval of an adult membership claim, please contact USASA’s Nick Schmitt at nschmitt@usasa.com or (708) 496-6876.