Notice to USA Water Ski & Wake Sports Active Members and Guest Members

If you are injured while participating in a USA-WSWS sanctioned event, please let the on-site Safety/Club Official or Event Organizer know of your injury so that an Incident Report form can be

prepared. If an Incident Report is not prepared to document your injury, your claim will likely be denied by the Participant Accident carrier.

Should you require medical treatment as a result of your injury, the on-site Safety/Club Official or Event Organizer will provide you with a Medical Claim form. The Incident Report form and the Medical Claim form are both available to all Clubs and Members via the USA-WSWS web site: www.usawaterski.org.

Please follow these instructions when submitting your Participant Accident medical claim:

DO NOT SUBMIT CLAIM FORMS, MEDICAL BILLS OR OTHER ITEMS TO USA-WSWS.

1. Submit your medical expenses to your primary medical/health insurance provider for consideration and payment. Your primary coverage would include group medical/health insurance available through your employer, spouse, parent or legal guardian, Medicare or other coverage. The USA-WSWS Participant Accident coverage is secondary (i.e. excess) to your primary coverage.
2. Your primary medical/health insurance carrier will issue an Explanation of Benefits (EOB) showing payment or denial of each medical expense related to your injury.
3. Once you receive the EOB paperwork from your primary medical/health insurance carrier, please complete the USA-WSWS Participant Accident Medical claim form. Be sure to attach the following documents to your completed USA-WSWS Participant Accident Medical Claim Form:​
   • The Itemized Insurance Billing form(s) from your physician (CMS-1500), hospital (UB-04) or other provider. These forms must show the following: Patient’s Name, Condition/Diagnosis, Type of Treatment, Date Expense Incurred and the Charges.
   • The Explanation of Benefits (EOB) form(s) showing payment or denial of each medical billing.
4. Submit your completed USA-WSWS Participant Accident Medical Claim form along with the Itemized Insurance Billing forms and your Explanation of Benefits form(s) to:

A-G ADMINISTRATORS, LLC PO BOX 21013

Eagan, MN 55121

(610) 933-0800 Telephone

(610) 933-4122 Facsimile

Secure upload portal: upload.agadministrators.com