* CSSA *
Connecticut State Soccer Association

Procedure for Filing an Insurance Claim for a Player Injury / Accident

 
C.S.S.A. procedure for filing an insurance claim for an injury. The C.S.S.A. is a member of the United States Adult Soccer Association (U.S.A.S.A.)
 
Instructions:
1. Player downloads the USASA Claim Form (in English or Spanish, links below) from the CSSA Website, AND NOWHERE ELSE. Please note that the form is a PDF file and you will need Adobe Reader (a free download from Adobe.com -- look under 'Download') to open and/or print the file:


For your convenience, these links below are DIRECTLY from the USASA insurance documents Website

Player Accident Claim Form (English)

Player Accident Claim Form (Español)
 
2. Player fills out the form completely (with help from his team manager/coach, if needed), except section 8. Player signs the form on page 2.
3. Player then sends the form to his team manager/coach for sign-off. Please make sure that the application form is complete and player’s pass number is added (ADD the player's pass number to Part B.1 , after you fill in Team Name.
4. Team manager/coach signs off and mails the form to the "league verification officer" to have the league verify that the injury is reported in the official USSF match report (referee's report), if applicable. If needed, the league can ask it's assignor or the referee directly to amend the report to include details of the injury (file a supplemental report).
5. League verification officer signs off and sends the claim form to the USASA verification officer for the CSSA for final sign-off.
6. CSSA then sends the completed claim form to USASA's insurance company.
 
Coverage Information:
Please go to the USASA Insurance Overview Website for insurance plan summary information.