LITTLE LEAGUE
®
BASEBALL AND SOFTBALL
ACCIDENT NOTIFICATION FORM
INSTRUCTIONS
1. Thisformmustbecompletedbyparents(ifclaimantisunder19yearsofage)andaleagueofcialandforwardedtoLittleLeague
Headquarterswithin20daysaftertheaccident.Aphotocopyofthisformshouldbemadeandkeptbytheclaimant/parent.Initialmedical/
dentaltreatmentmustberenderedwithin30daysoftheLittleLeagueaccident.
2. Itemizedbillsincludingdescriptionofservice,dateofservice,procedureanddiagnosiscodesformedicalservices/suppliesand/orother
documentationrelatedtoclaimforbenetsaretobeprovidedwithin90daysaftertheaccidentdate.Innoeventshallsuchproofbe
furnishedlaterthan12monthsfromthedatethemedicalexpensewasincurred.
3. Whenotherinsuranceispresent,parentsorclaimantmustforwardcopiesoftheExplanationofBenetsorNotice/LetterofDenialfor
eachchargedirectlytoLittleLeagueHeadquarters,evenifthechargesdonotexceedthedeductibleoftheprimaryinsuranceprogram.
4. Policyprovidesbenetsforeligiblemedicalexpensesincurredwithin52weeksoftheaccident,subjecttoExcessCoverageand
Exclusionprovisionsoftheplan.
5. Limiteddeferredmedical/dentalbenetsmaybeavailablefornecessarytreatmentincurredafter52weeks.Refertoinsurancebrochure
providedtotheleaguepresident,orcontactLittleLeagueHeadquarterswithintheyearofinjury.
6. AccidentClaimFormmustbefullycompleted-includingSocialSecurityNumber(SSN)-forprocessing.
LeagueName LeagueI.D.
NameofInjuredPerson/Claimant SSN SexAgeDateofBirth(MM/DD/YY)
NameofParent/Guardian,ifClaimantisaMinor HomePhone(Inc.AreaCode) Bus.Phone(Inc.AreaCode)
( ) ( )
AddressofClaimant AddressofParent/Guardian,ifdifferent
TheLittleLeagueMasterAccidentPolicyprovidesbenetsinexcessofbenetsfromotherinsuranceprogramssubjecttoa$50deductible
perinjury.“Otherinsuranceprograms”includefamily’spersonalinsurance,studentinsurancethroughaschoolorinsurancethroughan
employerforemployeesandfamilymembers.PleaseCHECKtheappropriateboxesbelow.IfYES,followinstruction3above.
IherebycertifythatIhavereadtheanswerstoallpartsofthisformandtothebestofmyknowledgeandbelieftheinformationcontainedis
completeandcorrectashereingiven.
Iunderstandthatitisacrimeforanypersontointentionallyattempttodefraudorknowinglyfacilitateafraudagainstaninsurerby
submittinganapplicationorlingaclaimcontainingafalseordeceptivestatement(s).SeeRemarkssectiononreversesideofform.
Iherebyauthorizeanyphysician,hospitalorothermedicallyrelatedfacility,insurancecompanyorotherorganization,institutionorperson
thathasanyrecordsorknowledgeofme,and/ortheabovenamedclaimant,orourhealth,todisclose,wheneverrequestedtodosoby
LittleLeagueand/orNationalUnionFireInsuranceCompanyofPittsburgh,Pa.Aphotostaticcopyofthisauthorizationshallbeconsidered
aseffectiveandvalidastheoriginal.
Date
Date
Claimant/Parent/GuardianSignature(Inatwoparenthousehold,bothparentsmustsignthisform.)
Claimant/Parent/GuardianSignature
DateofAccident TimeofAccident TypeofInjury
AM PM
Describeexactlyhowaccidenthappened,includingplayingpositionatthetimeofaccident:
Checkallapplicableresponsesineachcolumn:
BASEBALL
SOFTBALL
CHALLENGER
TAD(2NDSEASON)
CHALLENGER (5-18)
T-BALL (5-8)
MINOR (7-12)
LITTLELEAGUE(9-12)
JUNIOR (13-14)
SENIOR (14-16)
BIGLEAGUE (16-18)
PLAYER
MANAGER,COACH
VOLUNTEERUMPIRE
PLAYERAGENT
OFFICIALSCOREKEEPER
SAFETYOFFICER
VOLUNTEERWORKER
TRYOUTS
PRACTICE
SCHEDULEDGAME
TRAVELTO
TRAVELFROM
TOURNAMENT
OTHER(Describe)
SPECIALEVENT
(NOTGAMES)
SPECIALGAME(S)
(Submitacopyof
yourapprovalfrom
LittleLeague
Incorporated)
Send Completed Form To:
LittleLeague
®
International
539USRoute15Hwy,POBox3485
WilliamsportPA17701-0485
Accident Claim Contact Numbers:
Phone:570-327-1674
PART1
Female Male
DoestheinsuredPerson/Parent/Guardianhaveanyinsurancethrough:
EmployerPlan Yes No SchoolPlan Yes No
IndividualPlan Yes No DentalPlan Yes No
INTERMEDIATE (50/70) (11-13)
JUNIOR (12-14)
SENIOR (13-16)
(4-18)
(4-7)
(6-12)