LITTLE LEAGUE® BASEBALL AND SOFTBALLACCIDENT NOTIFICATION FORM

INSTRUCTIONS

1. Thisformmustbecompletedbyparents(ifclaimantisunder19yearsofage)andaleagueofficialandforwardedtoLittleLeagueHeadquarterswithin20daysaftertheaccident.Aphotocopyofthisformshouldbemadeandkeptbytheclaimant/parent.Initialmedical/dentaltreatmentmustberenderedwithin30daysoftheLittleLeagueaccident.

2. Itemizedbillsincludingdescriptionofservice,dateofservice,procedureanddiagnosiscodesformedicalservices/suppliesand/orotherdocumentationrelatedtoclaimforbenefitsaretobeprovidedwithin90daysaftertheaccidentdate.Innoeventshallsuchproofbefurnishedlaterthan12monthsfromthedatethemedicalexpensewasincurred.

3. Whenotherinsuranceispresent,parentsorclaimantmustforwardcopiesoftheExplanationofBenefitsorNotice/LetterofDenialforeachchargedirectlytoLittleLeagueHeadquarters,evenifthechargesdonotexceedthedeductibleoftheprimaryinsuranceprogram.

4. Policyprovidesbenefitsforeligiblemedicalexpensesincurredwithin52weeksoftheaccident,subjecttoExcessCoverageandExclusionprovisionsoftheplan.

5. Limiteddeferredmedical/dentalbenefitsmaybeavailablefornecessarytreatmentincurredafter52weeks.Refertoinsurancebrochureprovidedtotheleaguepresident,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

TheLittleLeagueMasterAccidentPolicyprovidesbenefitsinexcessofbenefitsfromotherinsuranceprogramssubjecttoa$50deductibleperinjury.“Otherinsuranceprograms”includefamily’spersonalinsurance,studentinsurancethroughaschoolorinsurancethroughanemployerforemployeesandfamilymembers.PleaseCHECKtheappropriateboxesbelow.IfYES,followinstruction3above.

IherebycertifythatIhavereadtheanswerstoallpartsofthisformandtothebestofmyknowledgeandbelieftheinformationcontainediscompleteandcorrectashereingiven.Iunderstandthatitisacrimeforanypersontointentionallyattempttodefraudorknowinglyfacilitateafraudagainstaninsurerbysubmittinganapplicationorfilingaclaimcontainingafalseordeceptivestatement(s).SeeRemarkssectiononreversesideofform.Iherebyauthorizeanyphysician,hospitalorothermedicallyrelatedfacility,insurancecompanyorotherorganization,institutionorpersonthathasanyrecordsorknowledgeofme,and/ortheabovenamedclaimant,orourhealth,todisclose,wheneverrequestedtodosobyLittleLeagueand/orNationalUnionFireInsuranceCompanyofPittsburgh,Pa.Aphotostaticcopyofthisauthorizationshallbeconsideredaseffectiveandvalidastheoriginal.

Date

Date

Claimant/Parent/GuardianSignature(Inatwoparenthousehold,bothparentsmustsignthisform.)

Claimant/Parent/GuardianSignature

DateofAccident TimeofAccident TypeofInjury

AM PMDescribeexactlyhowaccidenthappened,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)

PART1

Female Male

DoestheinsuredPerson/Parent/Guardianhaveanyinsurancethrough: EmployerPlan Yes No SchoolPlan Yes NoIndividualPlan Yes No DentalPlan Yes No

INTERMEDIATE (50/70) (11-13)

JUNIOR (12-14)SENIOR (13-16)BIG (14-18)

(4-18)(4-7)(6-12)