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Please note: The state field refers to the location where your employer is headquartered.
| Title | Download | Online Form | State |
|---|---|---|---|
| Accident Claim Form |
 Download Form (382.46 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Accidental Death & Dismemberment Employee Flyer |
Download Form (1.99 MB) |
AK, CA, MT, OR, UT, WA, WY | |
| Accidental Death & Dismemberment Employee Flyer - ID |
Download Form (1.99 MB) |
ID | |
| Accidental Dismemberment Claim Form |
Download Form (339.79 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| ADA Dental Claim Form |
Download Form (1.12 MB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Affidavit of Non-State Certified Domestic Partnership |
Download Form (69.45 KB) |
OR | |
| Affidavit of Non-State Registered Domestic Partnership |
Download Form (69.06 KB) |
WA | |
| Affidavit of Qualified Disabled Dependent |
Download Form (615.74 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Affidavit of Qualifying Domestic Partnership |
Download Form (68.82 KB) |
AK, CA, ID, MT, UT, WY | |
| Agent Standard Commission Schedule - AK |
Download Form (224.5 KB) |
AK | |
| Agent Standard Commission Schedule - CA |
Download Form (230.62 KB) |
CA | |
| Agent Standard Commission Schedule - MT, WY |
Download Form (206.81 KB) |
MT, WY | |
| Agent Standard Commission Schedule - OR, ID, UT |
Download Form (233.93 KB) |
ID, OR, UT | |
| Agent Standard Commission Schedule - WA |
Download Form (257.24 KB) |
WA | |
| Assignment of Life Insurance Proceeds Form for Life Claim Benefits |
Download Form (194.5 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Authorization for LifeMap to Release Information |
Download Form (179.09 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Beneficiary Designation Form |
Download Form (60.78 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Billing FAQ |
Download Form (60.86 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Cancer Only Critical Illness Employee Flyer |
Download Form (2.04 MB) |
AK, MT, OR, UT, WA, WY | |
| Cancer Only Critical Illness Employee Flyer - ID |
Download Form (2.04 MB) |
ID | |
| Cancer Plus Critical Illness Employee Flyer |
Download Form (2.17 MB) |
AK, MT, OR, UT, WA, WY | |
| Cancer Plus Critical Illness Employee Flyer - ID |
Download Form (2.17 MB) |
ID | |
| Critical Illness Cancer Care Claim Form |
Download Form (148.39 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Dental Health Article for Employees |
Download Form (91.36 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Dental Overview for Employers 2-299 |
Download Form (232.16 KB) |
AK, MT, OR, UT, WA, WY | |
| Dental Overview for Employers 300+ |
Download Form (189.4 KB) |
AK, MT, OR, UT, WA, WY | |
| Dental Overview for ID Employers 2-299 |
Download Form (232.99 KB) |
ID | |
| Dental Overview for ID Employers 300+ |
Download Form (189.99 KB) |
ID | |
| Dental Voluntary Group Employee Flyer |
Download Form (2.16 MB) |
AK, MT, OR, UT, WA, WY | |
| Dental Waiver Form |
Download Form (77.75 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Direct Deposit Form for Claim Benefits |
Download Form (88.72 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Employer Admin Center User Guide and FAQ |
Download Form (1.47 MB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Employer Admin Guide |
Download Form (770.42 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Evidence of Insurability (EOI) Frequently Asked Questions |
Download Form (196.59 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Evidence of Insurability (EOI) with HIPAA Authorization |
Download Form (957.47 KB) |
Online Form | AK, ID, MT, OR, UT, WA, WY |
| Extended Life Insurance Claim Form for Employee |
Download Form (301.28 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Extended Life Insurance Claim Form for Spouse |
Download Form (291.73 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Find a Dentist |
Download Form (82.62 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Find a Vision Provider - Group |
Download Form (185.93 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Group Dental Employee Flyer |
Download Form (1.59 MB) |
AK, CA, MT, OR, UT, WA, WY | |
| Group Dental Employee Flyer - ID |
Download Form (1.59 MB) |
ID | |
| Group Products Overview 10+ |
Download Form (760.88 KB) |
AK, MT, OR, UT, WA, WY | |
| Group Products Overview 10+ CA |
Download Form (2.3 MB) |
CA | |
| Group Products Overview 10+ ID |
Download Form (763.5 KB) |
ID | |
| Group Products Overview Express 2-9 CA |
Download Form (1.16 MB) |
CA | |
| HIPAA Authorization to Disclose Protected Health Information |
Download Form (259.78 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Individual Critical Illness and Emergency Treatment Benefit Claim Form |
Download Form (877.17 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Individual Critical Illness Plus Application - ID |
Download Form (857.59 KB) |
ID | |
| Individual Critical Illness Plus Application - OR |
Download Form (174.54 KB) |
OR | |
| Individual Critical Illness Plus Application - WA |
Download Form (1.03 MB) |
WA | |
| Individual Critical Illness Plus Beneficiary Form |
Download Form (83.93 KB) |
ID, OR, UT, WA | |
| Individual Critical Illness Plus Enrollment Packet - UT |
Download Form (723.12 KB) |
UT | |
| Individual Critical Illness Plus Flyer |
Download Form (112.64 KB) |
OR, UT, WA | |
| Individual Critical Illness Plus Flyer - ID |
Download Form (113.27 KB) |
ID | |
| Individual Dental Enrollment Packet - ID |
Download Form (914.11 KB) |
ID | |
| Individual Dental Enrollment Packet - OR |
Download Form (1.13 MB) |
OR | |
| Individual Dental Enrollment Packet - UT |
Download Form (921.42 KB) |
UT | |
| Individual Dental Enrollment Packet - WA |
Download Form (1.22 MB) |
WA | |
| Individual Dental Member Brochure - ID |
Download Form (193.48 KB) |
ID | |
| Individual Dental Member Brochure - OR |
Download Form (2.2 MB) |
OR | |
| Individual Dental Member Brochure - UT |
Download Form (193.42 KB) |
UT | |
| Individual Dental Member Brochure - WA |
Download Form (2.2 MB) |
WA | |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - ID |
Download Form (122.49 KB) |
ID | |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - OR |
Download Form (104.08 KB) |
OR | |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - UT |
Download Form (134.44 KB) |
UT | |
| Individual Dental Rates 4/1/2022 to 6/30/2022 - WA |
Download Form (125.33 KB) |
WA | |
| Individual Dental Rates 7/1/2022 to 9/30/2022 - ID |
Download Form (608.17 KB) |
ID | |
| Individual Dental Rates 7/1/2022 to 9/30/2022 - OR |
Download Form (614.63 KB) |
OR | |
| Individual Dental Rates 7/1/2022 to 9/30/2022 - UT |
Download Form (608.15 KB) |
UT | |
| Individual Dental Rates 7/1/2022 to 9/30/2022 - WA |
Download Form (611.63 KB) |
WA | |
| Individual Short Term Medical Enrollment Packet - ID |
Download Form (324.86 KB) |
ID | |
| Individual Short Term Medical Enrollment Packet - OR |
Download Form (498.14 KB) |
OR | |
| Individual Short Term Medical Enrollment Packet - WA |
Download Form (491.59 KB) |
WA | |
| Individual Short Term Medical Pharmacy Reimbursement Form |
Download Form (32.81 KB) |
ID, OR, UT, WA | |
| Individual Short Term Medical Rates 4/1/2022 to 6/30/2022 - ID |
Download Form (168.19 KB) |
ID | |
| Individual Short Term Medical Rates 4/1/2022 to 6/30/2022 - OR |
Download Form (461.3 KB) |
OR | |
| Individual Short Term Medical Rates 4/1/2022 to 6/30/2022 - WA |
Download Form (465.87 KB) |
WA | |
| Individual Vision Rider Reimbursement Form |
Download Form (143.95 KB) |
ID, OR, UT | |
| Initial Premium Invoice |
Download Form (195.62 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Life Conversion Request for Information Form |
Download Form (228.07 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Life Employee Flyer |
Download Form (2.15 MB) |
AK, CA, MT, OR, UT, WA, WY | |
| Life Insurance Claim Form |
Download Form (284.21 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Life Insurance Worksheet |
Download Form (142.3 KB) |
AK, CA, MT, OR, UT, WA, WY | |
| Life Insurance Worksheet - Idaho |
Download Form (141.89 KB) |
ID | |
| LifeMap Advantages Beltone ID Card |
Download Form (41.49 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| LifeMap Advantages Member Flyer |
Download Form (885.84 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| LifeMap Protect 10 Benefit Summary |
Download Form (421.55 KB) |
ID, OR, UT, WA | |
| LifeMap Protect 20 Benefit Summary |
Download Form (421.11 KB) |
ID, OR, UT, WA | |
| LifeMap Protect 30 Benefit Summary |
Download Form (792.69 KB) |
ID, OR, UT, WA | |
| LifeMap Protect Plans Flyer |
Download Form (507.29 KB) |
ID, OR, UT, WA | |
| Long Term Disability Claim Form |
Download Form (570.96 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Long Term Disability Employee Flyer |
Download Form (2.09 MB) |
AK, CA, MT, OR, UT, WA, WY | |
| Long Term Disability Employee Flyer - ID |
Download Form (2.09 MB) |
ID | |
| Notice of Privacy Practices - STM, Vision, Dental |
Download Form (126.25 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Privacy Notice |
Download Form (24.05 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Provider EFT Enrollment Form |
Download Form (225.17 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Regence Life Solutions Life 10 Benefit Summary |
Download Form (195.14 KB) |
ID, OR, UT, WA | |
| Regence Life Solutions Life 20 Benefit Summary |
Download Form (197.97 KB) |
ID, OR, UT, WA | |
| Regence Life Solutions Life 30 Benefit Summary |
Download Form (197.78 KB) |
ID, OR, UT, WA | |
| Risk Evaluation Form |
Download Form (89.29 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Short Term Disability Claim Form |
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 | |
| Short Term Disability Overview for Employers |
Download Form (486.03 KB) |
AK, MT, OR, UT, WA, WY | |
| Short Term Disability Overview for ID Employers |
Download Form (486.52 KB) |
ID | |
| Small Group (10-25 Employees) Basic Life and AD&D Benefit Summary |
Download Form (782.55 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (10-25 Employees) Dental Plan J Benefit Summary |
Download Form (768.55 KB) |
ID, OR, UT, WA | |
| Small Group (10-25 Employees) Dental Plan K and L Benefit Summary |
Download Form (784.06 KB) |
ID, OR, UT, WA | |
| Small Group (10-25 Employees) Dental Plan Options |
Download Form (185.43 KB) |
ID, OR, UT | |
| Small Group (10-25 Employees) LTD Benefit Summary |
Download Form (743.34 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (10-25 Employees) Master Application |
Download Form (99.58 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Small Group (10-25 Employees) STD Benefit Summary |
Download Form (757.67 KB) |
AK, ID, MT, OR, UT, WY | |
| Small Group (10-25 Employees) Voluntary Life and AD&D Benefit Summary |
Download Form (759.76 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (10-25 Employees) Washington Dental Plan Options (Active PPO Plans) |
Download Form (168.58 KB) |
WA | |
| Small Group (10-25 Employees) Washington Dental Plan Options (Passive PPO Plans) |
Download Form (179.82 KB) |
WA | |
| Small Group (2-25 Employees) Implementation Worksheet |
Download Form (1.05 MB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Small Group (2-25 Employees) Service Directory |
Download Form (128.92 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Small Group (2-25 Employees) Vision Benefit Summary - $130 Frame Allowance |
Download Form (786.31 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (2-25 Employees) Vision Benefit Summary - $150 Frame Allowance |
Download Form (787.66 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (2-25 Employees) Washington Dental Plan L with TMJ Benefit Summary |
Download Form (802.39 KB) |
WA | |
| Small Group (2-9 Employees) Basic Life and AD&D Benefit Summary |
Download Form (811.02 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (2-9 Employees) Dental Plan A Benefit Summary |
Download Form (797.3 KB) |
ID, OR, UT | |
| Small Group (2-9 Employees) Dental Plan C Benefit Summary |
Download Form (749.16 KB) |
ID, OR, UT | |
| Small Group (2-9 Employees) Dental Plan Options |
Download Form (179.43 KB) |
ID, OR, UT | |
| Small Group (2-9 Employees) LTD Benefit Summary |
Download Form (787.68 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (2-9 Employees) Master Application |
Download Form (831.55 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Small Group (2-9 Employees) STD Benefit Summary |
Download Form (761.84 KB) |
AK, ID, MT, OR, UT, WY | |
| Small Group (2-9 Employees) Voluntary Life and AD&D Benefit Summary |
Download Form (759.35 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group (2-9 Employees) Washington Dental Plan J Benefit Summary |
Download Form (862.98 KB) |
WA | |
| Small Group (2-9 Employees) Washington Dental Plan K Benefit Summary |
Download Form (778.98 KB) |
WA | |
| Small Group (2-9 Employees) Washington Dental Plan L Benefit Summary |
Download Form (802.8 KB) |
WA | |
| Small Group (2-9 Employees) Washington Dental Plan Options |
Download Form (180.17 KB) |
WA | |
| Small Group (5-9 Employees) Washington Dental Plan L with Ortho Benefit Summary |
Download Form (885.28 KB) |
WA | |
| Small Group Basic Life and AD&D Plan Options |
Download Form (169.82 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group LTD Plan Options |
Download Form (172.61 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group STD Plan Options |
Download Form (169.43 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group Vision Plan Options |
Download Form (265.54 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Small Group Voluntary Life and AD&D Plan Options |
Download Form (173.33 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| STM Authorization For Use and Disclosure of Protected Health Information |
Download Form (129.8 KB) |
ID, OR, UT, WA | |
| Vision Employee Flyer |
Download Form (1.31 MB) |
AK, MT, OR, UT, WA, WY | |
| Vision Employee Flyer - ID |
Download Form (1.31 MB) |
ID | |
| Vision Employee Waiver Form |
Download Form (243.78 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Vision Out of Network Reimbursement Form |
Download Form (293.57 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Voluntary Accident Employee Flyer |
Download Form (3.09 MB) |
AK, MT, OR, UT, WA, WY | |
| Voluntary Accident Employee Flyer - ID |
Download Form (3.09 MB) |
ID | |
| Voluntary Accidental Death & Dismemberment Employee Flyer |
Download Form (1.99 MB) |
AK, MT, OR, UT, WA, WY | |
| Voluntary Accidental Death & Dismemberment Employee Flyer - ID |
Download Form (1.99 MB) |
ID | |
| Voluntary Group Dental Employee Flyer |
Download Form (1.09 MB) |
AK, MT, OR, UT, WA, WY | |
| Voluntary Group Dental Employee Flyer - ID |
Download Form (2.41 MB) |
ID | |
| Voluntary Life Employee Flyer |
Download Form (2.16 MB) |
AK, MT, OR, UT, WA, WY | |
| Voluntary Life Employee Flyer ID |
Download Form (2.16 MB) |
ID | |
| Voluntary Long Term Disability Employee Flyer |
Download Form (260.77 KB) |
AK, MT, OR, UT, WA, WY | |
| Voluntary Long Term Disability Employee Flyer - ID |
Download Form (261.1 KB) |
ID | |
| Voluntary Short Term Disability Employee Flyer |
Download Form (1.33 MB) |
AK, MT, OR, UT, WA, WY | |
| Voluntary Short Term Disability Employee Flyer - ID |
Download Form (1.33 MB) |
ID | |
| Wellness Benefit Statement |
Download Form (65.09 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |