Fill and Sign the Pacificare Authorization Form

LITTLE LEAGUE® BASEBALL AND SOFTBALL ACCIDENT NOTIFICATION FORM INSTRUCTIONS 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 1. This 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. League Name League I.D. Name of Injured Person/Claimant PART 1 SSN Date of Birth (MM/DD/YY) Age Sex  Female  Male Home Phone (Inc. Area Code) Bus. Phone (Inc. Area Code) ( ) ( ) Name of Parent/Guardian, if Claimant is a Minor Address of Claimant Address of Parent/Guardian, if different The Little League Master Accident Policy provides benefits in excess of benefits 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. Does the insured Person/Parent/Guardian have any insurance through: Date of Accident Time of Accident AM Employer Plan Individual Plan Yes Yes No No School Plan Dental Plan Yes Yes No No Type of Injury PM Describe exactly how accident happened, including playing position at the time of accident: Check all applicable responses in each column:  BASEBALL  CHALLENGER (4-18) (5-18)  SOFTBALL  T-BALL (5-8) (4-7)  CHALLENGER  MINOR (7-12) (6-12)  TAD (2ND SEASON)  LITTLE LEAGUE 9-12) ( INTERMEDIATE  JUNIOR (50/70) (11-13) (13-14)  JUNIOR (12-14)(14-16) SENIOR  SENIOR (13-16) BIG LEAGUE (16-18) BIG (14-18)        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) 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 filing 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 Claimant/Parent/Guardian Signature (In a two parent household, both parents must sign this form.) Date Claimant/Parent/Guardian Signature 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 fines and confinement in state prison. For Residents of New York: Any person who knowingly and with the intent to defraud any insurance company or other person files 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 five 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 files 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 benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. PART 2 - LEAGUE STATEMENT (Other than Parent or Claimant) Name of Injured Person/Claimant League I.D. Number Name of League Name of League Official Position in League Address of League Official 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. PART OF BODY INJURY POSITION WHEN INJURED  01 ABDOMEN  01 ABRASION  01 1ST  02 ANKLE  02 BITES  02 2ND  03 ARM  03 CONCUSSION  03 3RD  04 BACK  04 CONTUSION  04 BATTER  05 CHEST  05 DENTAL  05 BENCH  06 EAR  06 DISLOCATION  06 BULLPEN  07 ELBOW  07 DISMEMBERMENT  07 CATCHER  08 EYE  08 EPIPHYSES  08 COACH  09 FACE  09 FATALITY  09 COACHING BOX  10 FATALITY  10 FRACTURE  10 DUGOUT  11 FOOT  11 HEMATOMA  11 MANAGER  12 HAND  12 HEMORRHAGE  12 ON DECK  13 HEAD  13 LACERATION  13 OUTFIELD  14 HIP  14 PUNCTURE  14 PITCHER  15 KNEE  15 RUPTURE  15 RUNNER  16 LEG  16 SPRAIN  16 SCOREKEEPER  17 LIPS  17 SUNSTROKE  17 SHORTSTOP  18 MOUTH  18 OTHER  18 TO/FROM GAME  19 NECK  19 UNKNOWN  19 UMPIRE  20 NOSE  20 PARALYSIS/  20 OTHER  21 SHOULDER PARAPLEGIC  21 UNKNOWN  22 SIDE  22 WARMING UP  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 fields? 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 Notification is true and correct as stated, to the best of my knowledge. Date League Official Signature