Secondary Medical Insurance

Process:

The online medical claim is required to be submitted by the Club Administrator who was present at the time of the accident. No other person(s) are authorized to initiate a claim form. If someone other than the Club Administrator submits the claim, it will be denied.

 

Contact Keli Bitow at KeliB@washingtonyouthsoccer.org with any questions or concerns you may have regarding the online claims submission process.

 

**Please note that there is a $500 deductible.
    

Regardless of when the accident occurred, the parent will be required to provide the following information to the Club Administrator:

 

  • Injured player’s first and last name
  • Date of injury
  • Injured player’s address
  • Detailed explanation of sustained injury
  • Injured player’s date of birth
  • Club/team name
  • Type of injury (concussion, muscular, etc.)
  • Event type
  • Parent’s first and last name
  • Name of facility/field
  • Parent’s contact information (phone & email)
  • Location of facility/field

 

IF THE ACCIDENT OCCURRED ON OR AFTER 9/1/19: 

 

Step 1:
Athlete’s parent or legal guardian must fill out and sign the Participant Accident Claim Form and email to Club Administrator, along with itemized medical provider bills and an explanation of benefits (EOB) from their primary insurance carrier.

Step 2:
Club Administrator signs the claim form as the Special Risk Organization.

Step 3:
Club Administrator emails the claim form, itemized medical provider bills, and explanation of benefits (EOB) to Claims@agadm.com.

Step 4:
Once approved, the parent will receive an email from A-G Administrators on how to proceed with their claim.
 

Parents can communicate with A-G Administrators directly once the claim is submitted and approved.

A-G Administrators, Inc.
Claims Department
P.O. Box 979
Valley Forge, PA 19482

(610) 933-0800 (Phone)
(800) 634-8628 (Toll-Free)
 

IF THE ACCIDENT OCCURRED ON OR BEFORE 8/31/19: 
 

Step 1

After the Club Administrator completes the form at the link below, a Confirmation of Submission email from Pullen Insurance will be sent to the injured person’s parent. The email address the confirmation will come from is pullenins@pullenins.com, so please check your spam filters if you have not received notice within 1 week.

 
To complete the Online Medical Claim Form please click on the following link: two.pullenins.com/WAS/WASOverview.asp.
 

Step 2
Once approved, the parent will receive an email with the claim form as a PDF attachment. The parent(s) will need to send the claim form to the insurer, with the itemized medical provider bills and explanation of benefits (EOB) from the claimant’s primary insurance carrier.