Forms to Request Payments, Refunds or Credits
Use to request a 5-payment or 7-payment plan for the Competitive Program
This link will take you to our Financial Assistance page
Use to request a credit or voucher code for Comp registration
For Comp, receive a voucher code prior to registration or a credit adjustment after
For Rec, receive a voucher code prior to registration
Use to request a refund or credit due to season-ending injury or moving
Injuries and Insurance Forms and Links
All registered players are covered by supplemental medical insurance provided by the organization under which they play. Comp players are covered through FYSA, Comp NPL players are covered through FYSA and U.S. Club, Rec players in BYSL are covered through FYSA, Rec in-house players are covered through USSSA.
If your player is injured during a game or at practice, you can file a claim to help cover the costs of medical treatment.
Player injuries must be reported to the Club. Complete the form electronically and submit it to email@example.com or give handwritten reports to Directors. The fillable PDF can be typed in and saved.
To be filled and presented to the Club at the time of the incident or shortly thereafter.
From the Claim Instructions
Excess Coverage: Accident medical expenses are covered under this policy on an Excess Basis, and benefits will only be paid under this plan after your own personal or group insurance (including Health Maintenance Organizations) has paid out its benefits. Please note that you must follow your primary insurance carrier’s eligibility criteria (i.e., to be treated in-network, if required by HMO, etc) in order for this policy to consider your expenses for payment. If you receive Government or State Aid Insurance, (Medicaid, Medicare, etc) this insurance may be Primary.
Payment under this policy will be made according to usual and customary guidelines. This
means that the basis for payment of specific medical or dental services is based on the
average cost of that service by region. This policy does not automatically pay for services in
full; it pays based on the “usual and customary” fee for that service in your area.
Claim Guidelines: You have up to 15 months from the date of injury to submit claim form. For claims to be eligible for coverage you must seek medical attention within 90 days from date of injury.
Insurance Claim Verification Form (#R011, fillable PDF).
The team coach or manager will submit this form for processing when a parent submits an insurance claim for one of your players. This information provides verification of the player's injury prior to submitting the claim to the insurance company for review.
US Club Insurance Claim page with Claim Form and instructions.
USSSA Insurance - Contact firstname.lastname@example.org
Space Coast United Soccer Club | P.O. Box 410301, Melbourne, FL 32941 | email@example.com