New Claim Form

New Claim
Let's get started submitting your new claim. You must complete each section in its entirety and once you click 'Submit' in the final section, you will be directed to a 'Success' page.

You will receive TWO emails. One is a confirmation with a password you will need to download your completed claim forms in the other email.

Please allow 1-2 business days for a member of our team to reach out to you. If you have completed this form on a Friday, Saturday, Sunday, or a holiday, please be advised that you might not be contacted until the next business day(s).

WATCH FOR COMMUNICATION FROM THE FOLLOWING:

Calls could come from area codes: (480 or 602)

Emails could come from:

@bluestarclaims.com

@origamirisk.com

@jotform.bluestarclaims.com
Blue Star Claims LLC
21001 N. Tatum Blvd., Suite 1630-646
Phoenix, AZ 85050

Fax: (480) 579-2476
Email: intake@bluestarclaims.com
Name of person filling out this form:*

First NameLast Name
Phone Number of person filling out this form:*
(your preferred contact number)
Email Address of person filling out this form:*
Are you the Independent Contractor:*

YesNoUnsureOther
Name of Independent Contractor:*

First NameLast Name

Coverage Disclosure
Welcome Independent Contractor. We are happy to be of service to you.

Please remember we only administer injury claims sustained by you.

We do not offer the following (please do not report these):

Auto claims
Injuries to other people
Physical damage to your vehicle or other person’s vehicle
Property damage
Please contact your Contract Company for these items

Disclaimer:
Coverage is subject to the policy terms, conditions, limitations and exclusions. If there is a conflict between the information shown here and the actual insurance policy, the policy will govern. The policy is underwritten by the Insurance Company and Blue Star Claims is the Third Party Administrator for the Insurance Company and does not write insurance or sell insurance. Claim questions can be directed to Blue Star Claims. Please contact your insurance broker or Contract Company for assistance in policy questions. Please note that by submitting this claim, this is not a guarantee of coverage. Until you receive notification from us that the claim has been established and coverage verified, there is no coverage guarantee.
Your Name:*

First NameLast Name
Today's Date:*

MonthDayYear
Signature required to authorize you have read and acknowledged the above Coverage Disclosure.*

Clear

Information Disclosure
By signing below and submitting this form, I AUTHORIZE Blue Star Claims, LLC (“Blue Star”) to disclose any information and records about myself, including the information I have provided to it. This includes but is not limited to, my medical findings, diagnosis, treatment, treatment summaries, psychological or psychiatric evaluations, prognosis, clinic notes, diagnostic reports or radiology films, physical therapy records, pharmacy records, or any other health information in your records. I understand that based on the information released it may include information related to any substance abuse.

I UNDERSTAND that the information furnished may be used to evaluate and verify my claim for benefits for a work related injury or occupational disease. The information obtained is relevant to an occupational accident claim(s) and may be used by persons or organizations performing a service related to, or adjudicating the claim(s).

THIS AUTHORIZATION will expire 90 days following a resolution/closure of the occupational injury claim(s) but I may revoke it by sending a revocation in writing to the requesting party. Revocation of this authorization will not be valid if the requesting party has taken action in reliance upon such authorization. Please note that the information disclosed or used pursuant to this authorization may be subject to re-disclosure and would, therefore, no longer be protected under the terms of the HIPAA privacy rule.

A COPY of this authorization shall be deemed to have the same authority as the original.

I hereby certify that I have read the provisions in this authorization. I understand and agree to its terms, and authorize disclosure of the information described above.

Requesting Party: Blue Star Claims LLC

Address: 21001 North Tatum Blvd., Ste. 1630-646 Phoenix, AZ 85050

Phone Number: (480) 579-2501

Fax Number: (480) 579-2476

The information furnished may be used to evaluate and verify my claim for benefits for a work related injury or occupational disease. The information obtained is relevant to an occupational accident claim(s) and may be used by persons or organizations performing a service related to, or adjudicating the claim(s).
Your Name:*

First NameLast Name
Today's Date:*

MonthDayYear
Signature required to authorize you have read and acknowledged the above Information Disclosure*

Clear

HIPAA Disclosure

AUTHORIZATION TO DISCLOSE, RELEASE AND USE PROTECTED HEALTH INFORMATION (HIPAA COMPLIANT)
This authorization permits you to release a copy of any and all records (even those which predate the injury listed below) in your possession regarding any pre-employment physicals, DOT physicals, post offer physicals, medical treatment and/or hospitalization of:
Name of Injured person:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Please Confirm Date of Birth!
Social Security Number:
Date of Injury:*

MonthDayYear
Date
I AUTHORIZE you to disclose any information and records regarding the above named individual in your possession. This includes but is not limited to, your medical findings, diagnosis, treatment, treatment summaries, psychological or psychiatric evaluations, prognosis, clinic notes, diagnostic reports or radiology films, physical therapy records, pharmacy records, or any other health information in your records. I understand that based on the information released it may include information related to any substance abuse.

I UNDERSTAND that the information furnished may be used to evaluate and verify my claim for benefits for a work related injury or occupational disease. The information obtained is relevant to an occupational accident claim(s) and may be used by persons or organizations performing a service related to, or adjudicating the claim(s).

THIS AUTHORIZATION will expire 90 days following a resolution/closure of the occupational injury claim(s) but may be revoked by signator in writing to the requesting party. Revocation of this authorization will not be valid if the requesting party has taken action in reliance upon such authorization. Please note that the information disclosed or used pursuant to this authorization may be subject to re-disclosure and would, therefore, no longer be protected under the terms of the HIPAA privacy rule.

A PHOTOSTATIC COPY of this authorization shall be deemed to have the same authority as the original. I hereby certify that I have read the provisions in this authorization. I understand and agree to its terms, and authorize disclosure of the information described above.
Today's Date:*

MonthDayYear
Signature required to authorize you have read and acknowledge the above HIPAA Disclosure:*

Clear
Authorization to obtain non public personal and financial information:

Blue Star Claims will have complete and unrestricted rights to obtain, disclose, release or make use of personal or privileged information about me which may include financial and wage statements, tax records, settlement statements on income, applications for employment or any personnel records to assist in the investigation of my Occupation Injury claim.

This information is for the sole use of the designated persons and/or entities listed below. Unless required by applicable law or court order, this information will not be given in any identifiable form to any other unauthorized persons or entity unless I agree to release it in writing.
Today's Date:*

MonthDayYear
Signature required to authorize you have read and acknowledged the above HIPAA Disclosure:*

Clear

Medical Treatment Provider List
This form will expedite the investigation of your Occupational Accident claim under your Independent Contractor policy.

We may need to request prior medical records from doctors or facilities you have seen in the past. Please list any medical providers who have treated you for any medical condition(s) within the past 15 years.

Information provided on this Medical Treatment Provider List will be used by the requesting party:

Blue Star Claims LLC

21001 N. Tatum Blvd., Suite 1630-646
Phoenix, AZ 85050
Phone: (480) 579-2501
Fax: (480) 579-2476
Email: serviceteam@bluestarclaims.com
In the next 2 sections you will providing information for both CURRENT and PRIOR treating providers.

The first section will be for CURRENT treating providers.
The second section will be for PRIOR treating providers.
Are you CURRENTLY seeing any physician(s) for ANY reason (not limited just to this injury):*

YesNo
CURRENT Treating Providers:
Have you seen any PRIOR physician(s) for ANY reason (not limited just to this Accident/Injury):*

YesNo
PRIOR Treating Providers:
Today's Date*

MonthDayYear
Date
Signature*

Clear

Fraud Warning
PLEASE SEE BELOW FOR ALL STATES OTHER THAN NEW YORK.

FRAUD WARNING: RESIDENTS OF NEW YORK: 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 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. CLAIM FORM FRAUD STATEMENT - FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW:

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.

ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

CALIFORNIA: For your protection California law requires the following to appear on this form: 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.

COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

FLORIDA WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

KANSAS: 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 may be guilty of insurance fraud as determined by a court of law and may be subject to fines and confinement in prison.

KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a 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.

MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NEW MEXICO and 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.

NEW YORK: 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 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.

OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

TENNESSEE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

TEXAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

VIRGINIA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.
Today's Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

New Claim

Coverage Disclosure

Information Disclosure

HIPAA Disclosure

Claim Form

Medical Treatment Provider List

Fraud Warning