Accident Proof Of Loss Claim Form - Babe Ruth League, Inc. Page 2
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21712 Magnavox Way P.O. Box 2338
BABE RUTH LEAGUE, INC.
Fort Wayne, Indiana 46801
1-800-237-2917 Fax 1-260-459-5910
ACCIDENT PROOF OF LOSS
CLAIM FORM
CA #0334819
on behalf of Nationwide Life Insurance Company
PART II – TO BE COMPLETED BY LEAGUE OFFICIAL
League name:_________________________________________ Babe Ruth team name:__________________________________
League or authorized league official’s address:_____________________________________________________________________
City:__________________________________________________________________________State:_________Zip:____________
BASEBALL
SOFTBALL
CLAIMANT IS A:
ABSENCE FROM PLAY
(Please check one)
(Please check one)
(Please check one)
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Major Cal Ripken
Major 12 & Under
Player
Pre-Season
< One Week
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Minor Cal Ripken
Minor 12 & Under
Coach
Regular Season
1-3 Weeks
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13-15 League
14 & Under League
Manager
Tournament
3+ Weeks
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13 Prep League
16 & Under League
Non-Player Personnel
Travel Ball
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16-18 League
18 & Under League
Umpire
Dual Participation
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16 Prep League
World Series
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Bambino Buddy Ball
Injured person’s full name:_____________________________________________________ Date of birth:_____________________
Claimant’s social security number: ______________________________________________________________________________
Date/hour of accident: __________________Time: ________A.M./P.M. Place injury occurred: ______________________________
INJURY:
SIDE:
TIME:
DISPOSITION:
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Injured body part:______________________________
Left
Morning
On-site care only
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Condition:____________________________________
Right
Afternoon
Ambulance to __________________
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(laceration, concussion, fracture, sprain, etc.)
Both
Evening
____________________________
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N/A
Lights
City__________________________
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Fatality
Refused care
OCCASION:
LOCATION:
ACTIVITY:
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TO/FROM GAME
BASE: (1st) (2nd) (3rd) (HP)
BATTING
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WARMUPS
BASEPATH
RUNNING
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DURING GAME (_________ Inning)
INFIELD
SLIDING
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BETWEEN INNINGS
OUTFIELD
CATCHING
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TO/FROM PRACTICE
FOUL TERRITORY
FIELDING
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PRACTICE: (Early) (Mid) (Late)
DUGOUT
TAGGING
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PRACTICE GAME CONDITIONS
BULL PEN
THROWING
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OTHER:
LOCKER ROOM
PITCHING
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OTHER:
OTHER:
SITUATION:
DESCRIBE HOW ACCIDENT HAPPENED:
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HIT BY (Pitch) (Bat) (Foul) (Thrown Ball) (Batted Ball)
Other______________________________________
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COLLISION WITH: (Teammate) (Opponent) (Fence)
Other______________________________________
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NON-CONTACT INJURY
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FALL (Slip) (Trip) (Pushed)
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OTHER____________________________________
League
League
official’s name: ______________________________________ official’s signature:______________________________________
P
P
LEASE
RINT
Title:____________________________________________ Daytime phone:______________________ Date:________________
1309 1/07
COMPLETE AND RETURN TO K&K, CLAIMS DEPT., P.O. BOX 2338, FORT WAYNE, IN 46801.
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