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Get Usasa 1769-1 Form 2015-2026
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How to fill out the USASA 1769-1 Form online
Filling out the USASA 1769-1 Form online can streamline the claims process for injuries sustained during USA Soccer activities. This guide provides step-by-step instructions to ensure that users can complete the form accurately and efficiently.
Follow the steps to complete the form seamlessly.
- Press the ‘Get Form’ button to access the form and open it in your preferred editor.
- Begin by filling out Part A, which must be completed, dated, and signed by the injured person or their parent or guardian if under 18. Provide the name of the injured person, their complete mailing address, and contact numbers.
- Next, indicate the date of the accident and whether the injured person is enrolled in Medicare or Medicaid. If affirmative, include their Social Security or Health I.D. number.
- Provide the injured person's date of birth, gender, marital status, and current student status if applicable.
- Complete the health insurance section. If enrolled in health insurance, provide the name, group name, and policy number for all relevant plans. If not enrolled, you will need to provide written verification from the relevant parties.
- Proceed to Part B, ensuring it is fully completed and signed by a representative from your local organization. Fill in details about the team name, league name, state association, region, and the circumstances of the injury.
- Describe how the accident occurred, including the type of injury and the body part affected. Additionally, provide the name and contact number of the coach, manager, or referee who witnessed the accident.
- Once all necessary sections are filled out, sign the form to certify that the information is accurate. Gather any itemized bills related to the injury, along with any explanations of benefits from other insurance providers.
- Submit the completed form and attachments to your USASA State Association or Nationwide affiliate office. After validation, your claim will be sent to the USASA National Office and then to the insurance company.
- After submission, keep track of your claim and contact A-G Administrators if you have any further questions regarding your claim processing.
Begin completing your USASA 1769-1 Form online today to ensure your claims are processed timely and effectively.
This form is replaced by PS Form 1769/301, Accident Report, which is generated from the new Employee Health and Safety Application. Recycle unused copies of PS Form 1769 through your local recycling program. To report an accident using the new Employee Health and Safety Application*: n Go to http://blue.usps.gov/.