PLAYER ACCIDENT INSURANCE

Players registered each year through Colorado Soccer Association can file a claim for potential reimbursement of medical costs if injured during an MDWSC, CSA,  or USASA sanctioned event. REMEMBER, this is secondary insurance coverage that may cover out of pocket deductibles or excesses not covered by your primary policy (through work or spouse primary medical policies). For more general information, visit https://www.coloradosoccer.org/adult-insurance-claim. 

If you have been injured during an MDWSC scheduled game, follow the instructions below. Please check that the referee notes the incident on the game card. Also make sure you and your team manager sign your claim form.

1. Click on the insurance claim form button (to be updated).  Complete Parts A and B  (fill in all fields)
2. ​Player must sign Part A on signature line at bottom of page 1
3. Team manager must sign Part B on signature line at bottom of page 2
4. Player read the "Authorization" on page 3; sign and date at the bottom.
5. Forward the claim form to Lorri (rulesrefsmdwsc@gmail.com) 

PLAYER ACCIDENT CLAIM FORM

CLAIM FILING FORM INSTRUCTIONS

MDWSC will sign off on page 2 after verifying the player is in good standing and properly registered and forward the form and supporting documents (including game report) to CSA.  CSA will do the same and forward to USASA. USASA will sign off and send to the insurance carrier.

All future communication about your claim will be made by the insurance carrier directly with the player who filed the claim.  If you do not receive a letter from the insurance carrier (to be updated) within 2 weeks of submitting your claim to MDWSC, please contact Lorri (rulesrefsmdwsc@gmail.com).