Claim Forms

Title Download Online Form State
Accident Claim Form PDF icon Download Form (382.46 KB) AK, CA, ID, MT, OR, UT, WA, WY
Accidental Dismemberment Claim Form PDF icon Download Form (339.79 KB) AK, CA, ID, MT, OR, UT, WA, WY
ADA Dental Claim Form PDF icon Download Form (1.12 MB) AK, CA, ID, MT, OR, UT, WA, WY
Assignment of Life Insurance Proceeds Form for Life Claim Benefits PDF icon Download Form (194.5 KB) AK, CA, ID, MT, OR, UT, WA, WY
Critical Illness Cancer Care Claim Form PDF icon Download Form (148.39 KB) AK, CA, ID, MT, OR, UT, WA, WY
Direct Deposit Form for Claim Benefits PDF icon Download Form (88.72 KB) AK, CA, ID, MT, OR, UT, WA, WY
Extended Life Insurance Claim Form PDF icon Download Form (163.23 KB) AK, CA, ID, MT, OR, UT, WA, WY
Individual Critical Illness and Emergency Treatment Benefit Claim Form PDF icon Download Form (877.17 KB) AK, CA, ID, MT, OR, UT, WA, WY
Individual Critical Illness Plus Beneficiary Form PDF icon Download Form (83.93 KB) ID, OR, UT, WA
Individual Short Term Medical Pharmacy Reimbursement Form PDF icon Download Form (32.81 KB) ID, OR, UT, WA
Individual Vision Rider Reimbursement Form PDF icon Download Form (143.95 KB) ID, OR, UT
Life Insurance Claim Form PDF icon Download Form (284.21 KB) AK, CA, ID, MT, OR, UT, WA, WY
Long Term Disability Claim Form PDF icon Download Form (570.96 KB) AK, CA, ID, MT, OR, UT, WA, WY
Short Term Disability Claim Form PDF icon Download Form (803.12 KB) AK, ID, MT, OR, UT, WA, WY
Short Term Disability Claim Form - Employee's Statement Online Form AK, ID, MT, OR, UT, WA, WY
STM Authorization For Use and Disclosure of Protected Health Information PDF icon Download Form (129.8 KB) ID, OR, UT, WA
Vision Out of Network Reimbursement Form PDF icon Download Form (293.57 KB) AK, ID, MT, OR, UT, WA, WY
Wellness Benefit Statement PDF icon Download Form (65.09 KB) AK, CA, ID, MT, OR, UT, WA, WY

Filing a claim for insurance generally means something has gone wrong. At LifeMap we'll do our best to make the process simple and as stress free as possible so you can focus on more important things.

Use this tool to help find the appropriate claim form. Just download and fax or mail the forms to us. And don't hesitate to reach out with any questions you have along the way.