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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 |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Accidental Death & Dismemberment Employee Flyer |
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AK, CA, MT, OR, UT, WA, WY | |
Accidental Death & Dismemberment Employee Flyer - ID |
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ID | |
Accidental Dismemberment Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
ADA Dental Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Affidavit of Non-State Certified Domestic Partnership |
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OR | |
Affidavit of Non-State Registered Domestic Partnership |
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WA | |
Affidavit of Qualified Disabled Dependent |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Affidavit of Qualifying Domestic Partnership |
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AK, CA, ID, MT, UT, WY | |
Agent Standard Commission Schedule - AK |
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AK | |
Agent Standard Commission Schedule - CA |
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CA | |
Agent Standard Commission Schedule - MT, WY |
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MT, WY | |
Agent Standard Commission Schedule - OR, ID, UT |
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ID, OR, UT | |
Agent Standard Commission Schedule - WA |
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WA | |
Assignment of Life Insurance Proceeds Form for Life Claim Benefits |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Authorization for LifeMap to Release Information |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Beneficiary Designation Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Billing FAQ |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Cancer Only Critical Illness Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Cancer Only Critical Illness Employee Flyer - ID |
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ID | |
Cancer Plus Critical Illness Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Cancer Plus Critical Illness Employee Flyer - ID |
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ID | |
Critical Illness Cancer Care Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Dental Health Article for Employees |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Dental Overview for Employers 2-299 |
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AK, MT, OR, UT, WA, WY | |
Dental Overview for Employers 300+ |
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AK, MT, OR, UT, WA, WY | |
Dental Overview for ID Employers 2-299 |
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ID | |
Dental Overview for ID Employers 300+ |
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ID | |
Dental Voluntary Group Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Dental Waiver Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Direct Deposit Form for Claim Benefits |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Employer Admin Center User Guide and FAQ |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Employer Admin Guide |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Evidence of Insurability (EOI) Frequently Asked Questions |
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AK, ID, MT, OR, UT, WA, WY | |
Evidence of Insurability (EOI) with HIPAA Authorization |
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Online Form | AK, ID, MT, OR, UT, WA, WY |
Extended Life Insurance Claim Form for Employee |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Extended Life Insurance Claim Form for Spouse |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Find a Dentist |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Find a Vision Provider - Group |
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AK, ID, MT, OR, UT, WA, WY | |
Group Dental Employee Flyer |
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AK, CA, MT, OR, UT, WA, WY | |
Group Dental Employee Flyer - ID |
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ID | |
Group Products Overview 10+ |
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AK, MT, OR, UT, WA, WY | |
Group Products Overview 10+ CA |
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CA | |
Group Products Overview 10+ ID |
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ID | |
Group Products Overview Express 2-9 CA |
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CA | |
HIPAA Authorization to Disclose Protected Health Information |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Individual Critical Illness and Emergency Treatment Benefit Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Individual Critical Illness Plus Application - ID |
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ID | |
Individual Critical Illness Plus Application - OR |
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OR | |
Individual Critical Illness Plus Application - WA |
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WA | |
Individual Critical Illness Plus Beneficiary Form |
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ID, OR, UT, WA | |
Individual Critical Illness Plus Enrollment Packet - UT |
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UT | |
Individual Critical Illness Plus Flyer |
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OR, UT, WA | |
Individual Critical Illness Plus Flyer - ID |
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ID | |
Individual Dental Enrollment Packet - ID |
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ID | |
Individual Dental Enrollment Packet - OR |
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OR | |
Individual Dental Enrollment Packet - UT |
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UT | |
Individual Dental Enrollment Packet - WA |
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WA | |
Individual Dental Member Brochure - ID |
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ID | |
Individual Dental Member Brochure - OR |
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OR | |
Individual Dental Member Brochure - UT |
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UT | |
Individual Dental Member Brochure - WA |
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WA | |
Individual Dental Rates 4/1/2022 to 6/30/2022 - ID |
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ID | |
Individual Dental Rates 4/1/2022 to 6/30/2022 - OR |
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OR | |
Individual Dental Rates 4/1/2022 to 6/30/2022 - UT |
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UT | |
Individual Dental Rates 4/1/2022 to 6/30/2022 - WA |
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WA | |
Individual Dental Rates 7/1/2022 to 9/30/2022 - ID |
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ID | |
Individual Dental Rates 7/1/2022 to 9/30/2022 - OR |
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OR | |
Individual Dental Rates 7/1/2022 to 9/30/2022 - UT |
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UT | |
Individual Dental Rates 7/1/2022 to 9/30/2022 - WA |
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WA | |
Individual Short Term Medical Enrollment Packet - ID |
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ID | |
Individual Short Term Medical Enrollment Packet - OR |
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OR | |
Individual Short Term Medical Enrollment Packet - WA |
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WA | |
Individual Short Term Medical Pharmacy Reimbursement Form |
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ID, OR, UT, WA | |
Individual Short Term Medical Rates 4/1/2022 to 6/30/2022 - ID |
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ID | |
Individual Short Term Medical Rates 4/1/2022 to 6/30/2022 - OR |
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OR | |
Individual Short Term Medical Rates 4/1/2022 to 6/30/2022 - WA |
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WA | |
Individual Vision Rider Reimbursement Form |
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ID, OR, UT | |
Initial Premium Invoice |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Life Conversion Request for Information Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Life Employee Flyer |
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AK, CA, MT, OR, UT, WA, WY | |
Life Insurance Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Life Insurance Worksheet |
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AK, CA, MT, OR, UT, WA, WY | |
Life Insurance Worksheet - Idaho |
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ID | |
LifeMap Advantages Beltone ID Card |
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AK, CA, ID, MT, OR, UT, WA, WY | |
LifeMap Advantages Member Flyer |
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AK, CA, ID, MT, OR, UT, WA, WY | |
LifeMap Protect 10 Benefit Summary |
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ID, OR, UT, WA | |
LifeMap Protect 20 Benefit Summary |
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ID, OR, UT, WA | |
LifeMap Protect 30 Benefit Summary |
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ID, OR, UT, WA | |
LifeMap Protect Plans Flyer |
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ID, OR, UT, WA | |
Long Term Disability Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Long Term Disability Employee Flyer |
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AK, CA, MT, OR, UT, WA, WY | |
Long Term Disability Employee Flyer - ID |
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ID | |
Notice of Privacy Practices - STM, Vision, Dental |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Privacy Notice |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Provider EFT Enrollment Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Regence Life Solutions Life 10 Benefit Summary |
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ID, OR, UT, WA | |
Regence Life Solutions Life 20 Benefit Summary |
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ID, OR, UT, WA | |
Regence Life Solutions Life 30 Benefit Summary |
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ID, OR, UT, WA | |
Risk Evaluation Form |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Short Term Disability Claim Form |
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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 |
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AK, MT, OR, UT, WA, WY | |
Short Term Disability Overview for ID Employers |
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ID | |
Small Group (10-25 Employees) Basic Life and AD&D Benefit Summary |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (10-25 Employees) Dental Plan J Benefit Summary |
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ID, OR, UT, WA | |
Small Group (10-25 Employees) Dental Plan K and L Benefit Summary |
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ID, OR, UT, WA | |
Small Group (10-25 Employees) Dental Plan Options |
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ID, OR, UT | |
Small Group (10-25 Employees) LTD Benefit Summary |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (10-25 Employees) Master Application |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Small Group (10-25 Employees) STD Benefit Summary |
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AK, ID, MT, OR, UT, WY | |
Small Group (10-25 Employees) Voluntary Life and AD&D Benefit Summary |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (10-25 Employees) Washington Dental Plan Options (Active PPO Plans) |
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WA | |
Small Group (10-25 Employees) Washington Dental Plan Options (Passive PPO Plans) |
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WA | |
Small Group (2-25 Employees) Implementation Worksheet |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Small Group (2-25 Employees) Service Directory |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Small Group (2-25 Employees) Vision Benefit Summary - $130 Frame Allowance |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (2-25 Employees) Vision Benefit Summary - $150 Frame Allowance |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (2-25 Employees) Washington Dental Plan L with TMJ Benefit Summary |
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WA | |
Small Group (2-9 Employees) Basic Life and AD&D Benefit Summary |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (2-9 Employees) Dental Plan A Benefit Summary |
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ID, OR, UT | |
Small Group (2-9 Employees) Dental Plan C Benefit Summary |
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ID, OR, UT | |
Small Group (2-9 Employees) Dental Plan Options |
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ID, OR, UT | |
Small Group (2-9 Employees) LTD Benefit Summary |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (2-9 Employees) Master Application |
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AK, CA, ID, MT, OR, UT, WA, WY | |
Small Group (2-9 Employees) STD Benefit Summary |
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AK, ID, MT, OR, UT, WY | |
Small Group (2-9 Employees) Voluntary Life and AD&D Benefit Summary |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group (2-9 Employees) Washington Dental Plan J Benefit Summary |
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WA | |
Small Group (2-9 Employees) Washington Dental Plan K Benefit Summary |
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WA | |
Small Group (2-9 Employees) Washington Dental Plan L Benefit Summary |
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WA | |
Small Group (2-9 Employees) Washington Dental Plan Options |
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WA | |
Small Group (5-9 Employees) Washington Dental Plan L with Ortho Benefit Summary |
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WA | |
Small Group Basic Life and AD&D Plan Options |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group LTD Plan Options |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group STD Plan Options |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group Vision Plan Options |
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AK, ID, MT, OR, UT, WA, WY | |
Small Group Voluntary Life and AD&D Plan Options |
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AK, ID, MT, OR, UT, WA, WY | |
STM Authorization For Use and Disclosure of Protected Health Information |
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ID, OR, UT, WA | |
Vision Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Vision Employee Flyer - ID |
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ID | |
Vision Employee Waiver Form |
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AK, ID, MT, OR, UT, WA, WY | |
Vision Out of Network Reimbursement Form |
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AK, ID, MT, OR, UT, WA, WY | |
Voluntary Accident Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Voluntary Accident Employee Flyer - ID |
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ID | |
Voluntary Accidental Death & Dismemberment Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Voluntary Accidental Death & Dismemberment Employee Flyer - ID |
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ID | |
Voluntary Group Dental Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Voluntary Group Dental Employee Flyer - ID |
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ID | |
Voluntary Life Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Voluntary Life Employee Flyer ID |
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ID | |
Voluntary Long Term Disability Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Voluntary Long Term Disability Employee Flyer - ID |
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ID | |
Voluntary Short Term Disability Employee Flyer |
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AK, MT, OR, UT, WA, WY | |
Voluntary Short Term Disability Employee Flyer - ID |
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ID | |
Wellness Benefit Statement |
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AK, CA, ID, MT, OR, UT, WA, WY |
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