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Sponsored By:   Ice Miller
McLean, VA
 
 
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Accident Report

LITTLE LEAGUE® BASEBALL AND SOFTBALL

ACCIDENT NOTIFICATION FORM
 
INSTRUCTIONS:

1. The Accident Report Form must be completed by parents (if claimant is under 19 years of age) and a league official 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 benefits 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 Benefits 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 benefits 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 benefits 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