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 ofIcial and forwarded to Little L eague Headquarters within 20 days after the accident. A photocopy of this form should be made and kept by the claimant/parent. Initia l 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/supplie s and/or other documentation related to claim for beneIts are to be provided within 90 days after the accident date. In no event shall such pr oof 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 BeneIts or Notice/Letter of D enial for each charge directly to Little League Headquarters, even if the charges do not exceed the deductible of the primary insurance p rogram.
4. Policy provides beneIts for eligible medical expenses incurred within 52 weeks of the accident, subject to Excess Coverage a nd Exclusion provisions of the plan. ... more. less.
5. Limited deferred medical/dental beneIts 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.<br><br> League Name League I.D. Name of Injured Person/Claimant SSN Sex Age Date 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 beneIts in excess of beneIts from other insurance programs subject to a $50 deductible per injury. cOther insurance programs d include family 9s personal insurance, student insurance through a school or insurance thr ough 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 informat ion contained is complete and correct as herein given.<br><br> I understand that it is a crime for any person to intentionally attempt to defraud or knowingly facilitate a fraud against an i nsurer by submitting an application or Iling 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, instit ution 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 TRAVEL TO 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 Fax: 570-326- 9280 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 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 Ines and conInement in state prison.<br><br> For Residents of New York: Any person who knowingly and with the intent to defraud any insurance company or other person Iles an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerni ng any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not t o exceed Ive 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 Iles 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 beneIt or knowingly presents false infor mation in an application for insurance is guilty of a crime and may be subject to Ines and conInement in prison.<br><br> PART 2 - LEAGUE STATEMENT (Other than Parent or Claimant) Name of League Name of Injured Person/Claimant League I.D. Number Name of League OfIcial Position in League Address of League OfIcial 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 BY BAT 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 Ields?<br><br> 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 Polic y at the time of the reported accident. I also certify that the information contained in the Claimant 9s NotiIcation is true and correct as stated, to the best of my knowledge. Date League OfIcial Signature<br><br>