LITTLE LEAGUE
®
BASEBALL AND SOFTBALL
ACCIDENT NOTIFICATION FORM
INSTRUCTIONS
1. Thisformmustbecompletedbyparents(ifclaimantisunder19yearsofage)andaleagueofcialandforwardedtoLittleLeague
Headquarterswithin20daysaftertheaccident.Aphotocopyofthisformshouldbemadeandkeptbytheclaimant/parent.Initialmedical/
dentaltreatmentmustberenderedwithin30daysoftheLittleLeagueaccident.
2. Itemizedbillsincludingdescriptionofservice,dateofservice,procedureanddiagnosiscodesformedicalservices/suppliesand/orother
documentationrelatedtoclaimforbenetsaretobeprovidedwithin90daysaftertheaccidentdate.Innoeventshallsuchproofbe
furnishedlaterthan12monthsfromthedatethemedicalexpensewasincurred.
3. Whenotherinsuranceispresent,parentsorclaimantmustforwardcopiesoftheExplanationofBenetsorNotice/LetterofDenialfor
eachchargedirectlytoLittleLeagueHeadquarters,evenifthechargesdonotexceedthedeductibleoftheprimaryinsuranceprogram.
4. Policyprovidesbenetsforeligiblemedicalexpensesincurredwithin52weeksoftheaccident,subjecttoExcessCoverageand
Exclusionprovisionsoftheplan.
5. Limiteddeferredmedical/dentalbenetsmaybeavailablefornecessarytreatmentincurredafter52weeks.Refertoinsurancebrochure
providedtotheleaguepresident,orcontactLittleLeagueHeadquarterswithintheyearofinjury.
6. AccidentClaimFormmustbefullycompleted-includingSocialSecurityNumber(SSN)-forprocessing.
LeagueName LeagueI.D.
NameofInjuredPerson/Claimant SSN SexAgeDateofBirth(MM/DD/YY)
NameofParent/Guardian,ifClaimantisaMinor HomePhone(Inc.AreaCode) Bus.Phone(Inc.AreaCode)
( ) ( )
AddressofClaimant AddressofParent/Guardian,ifdifferent
TheLittleLeagueMasterAccidentPolicyprovidesbenetsinexcessofbenetsfromotherinsuranceprogramssubjecttoa$50deductible
perinjury.“Otherinsuranceprograms”includefamily’spersonalinsurance,studentinsurancethroughaschoolorinsurancethroughan
employerforemployeesandfamilymembers.PleaseCHECKtheappropriateboxesbelow.IfYES,followinstruction3above.
IherebycertifythatIhavereadtheanswerstoallpartsofthisformandtothebestofmyknowledgeandbelieftheinformationcontainedis
completeandcorrectashereingiven.
Iunderstandthatitisacrimeforanypersontointentionallyattempttodefraudorknowinglyfacilitateafraudagainstaninsurerby
submittinganapplicationorlingaclaimcontainingafalseordeceptivestatement(s).SeeRemarkssectiononreversesideofform.
Iherebyauthorizeanyphysician,hospitalorothermedicallyrelatedfacility,insurancecompanyorotherorganization,institutionorperson
thathasanyrecordsorknowledgeofme,and/ortheabovenamedclaimant,orourhealth,todisclose,wheneverrequestedtodosoby
LittleLeagueand/orNationalUnionFireInsuranceCompanyofPittsburgh,Pa.Aphotostaticcopyofthisauthorizationshallbeconsidered
aseffectiveandvalidastheoriginal.
Date
Date
Claimant/Parent/GuardianSignature(Inatwoparenthousehold,bothparentsmustsignthisform.)
Claimant/Parent/GuardianSignature
DateofAccident TimeofAccident TypeofInjury
AM PM
Describeexactlyhowaccidenthappened,includingplayingpositionatthetimeofaccident:
Checkallapplicableresponsesineachcolumn:
BASEBALL
SOFTBALL
CHALLENGER
TAD(2NDSEASON)
CHALLENGER (5-18)
T-BALL (5-8)
MINOR (7-12)
LITTLELEAGUE(9-12)
JUNIOR (13-14)
SENIOR (14-16)
BIGLEAGUE (16-18)
PLAYER
MANAGER,COACH
VOLUNTEERUMPIRE
PLAYERAGENT
OFFICIALSCOREKEEPER
SAFETYOFFICER
VOLUNTEERWORKER
TRYOUTS
PRACTICE
SCHEDULEDGAME
TRAVELTO
TRAVELFROM
TOURNAMENT
OTHER(Describe)
SPECIALEVENT
(NOTGAMES)
SPECIALGAME(S)
(Submitacopyof
yourapprovalfrom
LittleLeague
Incorporated)
Send Completed Form To:
LittleLeague
®
International
539USRoute15Hwy,POBox3485
WilliamsportPA17701-0485
Accident Claim Contact Numbers:
Phone:570-327-1674
PART1
Female Male
DoestheinsuredPerson/Parent/Guardianhaveanyinsurancethrough:
EmployerPlan Yes No SchoolPlan Yes No
IndividualPlan Yes No DentalPlan Yes No
INTERMEDIATE (50/70) (11-13)
JUNIOR (12-14)
SENIOR (13-16)
(4-18)
(4-7)
(6-12)
Accident & Health (U.S.)
For Residents of California:
Anypersonwhoknowinglypresentsafalseorfraudulentclaimforthepaymentofalossisguiltyofacrimeandmaybesubjecttonesand
connementinstateprison.
For Residents of New York:
Anypersonwhoknowinglyandwiththeintenttodefraudanyinsurancecompanyorotherpersonlesanapplicationforinsuranceor
statementofclaimcontaininganymateriallyfalseinformation,orconcealsforthepurposeofmisleading,informationconcerningany
factmaterialthereto,commitsafraudulentinsuranceact,whichisacrime,andshallalsobesubjecttoacivilpenaltynottoexceedve
thousanddollarsandthestatedvalueoftheclaimforeachsuchviolation.
For Residents of Pennsylvania:
Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonlesanapplicationforinsuranceorstatement
ofclaimcontaininganymateriallyfalseinformationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterial
theretocommitsafraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivilpenalties.
For Residents of All Other States:
Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenetorknowinglypresentsfalseinformationinan
applicationforinsuranceisguiltyofacrimeandmaybesubjecttonesandconnementinprison.
PART 2 - LEAGUE STATEMENT (Other than Parent or Claimant)
NameofLeague NameofInjuredPerson/Claimant LeagueI.D.Number
NameofLeagueOfcial PositioninLeague
AddressofLeagueOfcial TelephoneNumbers(Inc.AreaCodes)
Residence: ( )
Business: ( )
Fax: ( )
Wereyouawitnesstotheaccident? Yes No
Providenamesandaddressesofanyknownwitnessestothereportedaccident.
Checktheboxesforallappropriateitemsbelow.Atleastoneitemineachcolumnmustbeselected.
POSITION WHEN INJURED
01 1ST
02 2ND
03 3RD
04 BATTER
05 BENCH
06 BULLPEN
07 CATCHER
08 COACH
09 COACHINGBOX
10 DUGOUT
11 MANAGER
12 ONDECK
13 OUTFIELD
14 PITCHER
15 RUNNER
16 SCOREKEEPER
17 SHORTSTOP
18 TO/FROMGAME
19 UMPIRE
20 OTHER
21 UNKNOWN
22 WARMINGUP
INJURY
01 ABRASION
02 BITES
03 CONCUSSION
04 CONTUSION
05 DENTAL
06 DISLOCATION
07 DISMEMBERMENT
08 EPIPHYSES
09 FATALITY
10 FRACTURE
11 HEMATOMA
12 HEMORRHAGE
13 LACERATION
14 PUNCTURE
15 RUPTURE
16 SPRAIN
17 SUNSTROKE
18 OTHER
19 UNKNOWN
20 PARALYSIS/
PARAPLEGIC
PART OF BODY
01 ABDOMEN
02 ANKLE
03 ARM
04 BACK
05 CHEST
06 EAR
07 ELBOW
08 EYE
09 FACE
10 FATALITY
11 FOOT
12 HAND
13 HEAD
14 HIP
15 KNEE
16 LEG
17 LIPS
18 MOUTH
19 NECK
20 NOSE
21 SHOULDER
22 SIDE
23 TEETH
24 TESTICLE
25 WRIST
26 UNKNOWN
27 FINGER
CAUSE OF INJURY
01 BATTEDBALL
02 BATTING
03 CATCHING
04 COLLIDING
05 COLLIDINGWITHFENCE
06 FALLING
07 HITBYBAT
08 HORSEPLAY
09 PITCHEDBALL
10 RUNNING
11 SHARPOBJECT
12 SLIDING
13 TAGGING
14 THROWING
15 THROWNBALL
16 OTHER
17 UNKNOWN
Doesyourleagueusebreakawaybaseson: ALL SOME NONE ofyourelds?
Doesyourleagueusebattinghelmetswithattachedfaceguards? YES NO
IfYES,arethey Mandatory or Optional Atwhatlevelsaretheyused?
IherebycertifythattheabovenamedclaimantwasinjuredwhilecoveredbytheLittleLeagueBaseballAccidentInsurancePolicyatthe
timeofthereportedaccident.IalsocertifythattheinformationcontainedintheClaimant’sNoticationistrueandcorrectasstated,tothe
bestofmyknowledge.
Date LeagueOfcialSignature