Notification of a claim for an eligible member under the league’s Accident Insurance should be filed with Little League International within 20 days of the incident. Once we receive the complete claim form, the claimant will be assigned a claim number for any information that is submitted for the accident. The claim form should be submitted as soon as possible so we can begin a record of the accident and then the claimant can submit all itemized bills (includes procedure and diagnosis codes) from the medical providers as well as any primary insurance explanation of benefits (if applicable) for any treatments for the accident.
Part 1 - Claimant, or parent(s)/guardian(s), if claimant is a minor
Step 1The adult claimant or parent(s)/guardian(s), (if the claimant is a minor) must sign this section.
Step 2Give the name and address of the injured person, along with the name and address of the parent(s)/guardian(s), if claimant is a minor.
Step 3Fill out all section, including check marks in the appropriate boxes for all categories. Do not leave any section blank. This will cause a delay in processing your claim and a copy of the claim form will be returned to you for completion.
Step 4It is mandatory to forward information on other insurance. Without that information, there will be a delay in processing your claim. If no insurance, written verification from each parent/spouse employer must be submitted.
Step 5Be certain all necessary papers are attached to the claim form (See instruction 3). Only itemized bills that include date of treatment, type of treatment (procedure codes), total charge for each treatment, and reason(s) for treatment (diagnosis codes) are acceptable. We cannot accept balance due statements.
Step 6On dental claims, it is necessary to submit charges to the major medical and dental insurance company of the claimant, or parent(s)/guardian(s), if claimant is a minor. “Accident-related treatment to whole, sound, natural teeth as a direct and independent result of an accident” must be stated on the form and bills. Please forward a copy of the insurance company’s response (an Explanation of Benefits (EOB) Statement) to Little League International. Include the claimant’s name, league ID, and year of the injury on the form.
Part 2 - League Statement
Step 7This section must be filled out, signed, and dated by a league official (President, Safety Officer, etc.).
Step 8Fill out all sections, including check marks in the appropriate boxes for all categories. Do not leave any section blank. This will cause a delay in processing your claim and a copy of the claim form will be returned to you for completion.
When submitting the claim and all following information, please do so by mail. We cannot accept via email or fax as the claim form includes sensitive information. Please do not use the A Safety Awareness Program (ASAP) Injury/Incident Tracking Report form to file an Accident Insurance claim. This form is for internal league use only and does not constitute filing an insurance claim. For additional information, please refer to the Little League website and the 2017 Insurance Brochure.