Challenging Superior Players in Minnesota since 1988

First Report of Bodily Injury

PLEASE NOTE: Minnesota Baseball Alliance Accidental Medical Coverage and Dental is excess. Please submit all charges to your primary medical/dental carrier for review first, upon reply forward itemized bills along with Explanation of Benefits from primary Insurer to the League's Insurance Company.

Date of Incident

Time of Incident (AM or PM)

Injured Person

Minnesota Baseball Alliance Association

Hosting Club Name

Name of Park Incident occured

Does the injured person have other Medical Insurance?

Yes

No

If yes, please provide:

Name of Insurance Company

Policy Number

Did this take place during:

Practice

Competition

While traveling to or from an Event

Other

If during a competition, list name of event:

City and State event took place:

INJURED PERSON INFORMATION

Last Name:

First:

Middle:

Address:

City and State:

Zip Code:

Age:

Date of Birth:

Telephone Number (include Area Code)

Status:

Male

Female

Married

Single

Employer Name:

Address:

GUARDIAN/PARENT (if injured person is a minor)

Last Name:

First:

Middle:

Telephone Number (include Area Code):

Address:

City and State:

Zip Code:

Possible Pre-Existing Condition?

Yes

No

Incident Location

Medical Services:

Treated By:

Incident:

Classification:

Primary Injury:

Body Part Injured

Disposition

Describe how the incident occured:

Witness Information

	Name	Address	Telephone Number (include Area Code)
Witness 1
Witness 2

Name of Person submitting form:

Date:

Day Phone (include Area Code):

E-mail address

Indicates Response Required