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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 (77.92 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 - Alaska |
Download Form (950.69 KB) |
AK | |
| Agent Standard Commission Schedule - MT |
Download Form (953.75 KB) |
MT | |
| Agent Standard Commission Schedule - OR, ID, UT |
Download Form (958.14 KB) |
ID, OR, UT | |
| Agent Standard Commission Schedule - WA |
Download Form (955.2 KB) |
WA | |
| Agent Standard Commission Schedule - WY |
Download Form (951.57 KB) |
WY | |
| Assignment of Life Insurance Proceeds Form for Life Claim Benefits |
Download Form (194.5 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 (73.49 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 (736.95 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Evidence of Insurability (EOI) with HIPAA Authorization |
Download Form (78.87 KB) |
Online Form | AK, ID, MT, OR, UT, WA, WY |
| Express Group Basic Life and ADD Benefit Summary |
Download Form (110.72 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Express Group Basic Life and ADD Plan Options |
Download Form (75.1 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Express Group Dental Benefit Summary |
Download Form (72.39 KB) |
ID, OR, UT, WA | |
| Express Group Dental Benefit Summary for WA |
Download Form (83.46 KB) |
WA | |
| Express Group Dental Plan Options |
Download Form (91.74 KB) |
ID, OR, UT, WA | |
| Express Group Dental Plan Options for WA |
Download Form (82.41 KB) |
WA | |
| Express Group Implementation Worksheet (2-9) |
Download Form (88.16 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Express Group LTD Benefit Summary |
Download Form (74.03 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Express Group Master Application (2-9) |
Download Form (69.95 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Express Group STD Benefit Summary |
Download Form (75.68 KB) |
AK, ID, MT, OR, UT, WY | |
| Express Group Vision Benefit Summary |
Download Form (78.44 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Express Group Vision Plan Options |
Download Form (73.96 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Express Group Voluntary Life and ADD Benefit Summary |
Download Form (76.88 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Express Group Voluntary Life and ADD Plan Options |
Download Form (76.56 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Express Groups 2-9 Service Directory |
Download Form (33.92 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Express Groups STD and LTD Plan Options |
Download Form (77.31 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Extended Life Insurance Claim Form |
Download Form (163.23 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 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 Application - ID |
Download Form (136.36 KB) |
ID | |
| Individual Dental Application - OR |
Download Form (1.13 MB) |
OR | |
| Individual Dental Application - UT |
Download Form (131.54 KB) |
UT | |
| Individual Dental Application - 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 4/1/2020 to 6/30/2020 - ID |
Download Form (28.12 KB) |
ID | |
| Individual Dental Rates 4/1/2020 to 6/30/2020 - OR |
Download Form (31.74 KB) |
OR | |
| Individual Dental Rates 4/1/2020 to 6/30/2020 - UT |
Download Form (38.78 KB) |
UT | |
| Individual Dental Rates 4/1/2020 to 6/30/2020 - WA |
Download Form (29.06 KB) |
WA | |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - ID |
Download Form (28.16 KB) |
ID | |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - OR |
Download Form (31.78 KB) |
OR | |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - UT |
Download Form (38.81 KB) |
UT | |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - WA |
Download Form (29.14 KB) |
WA | |
| Individual Short Term Medical Enrollment Packet - OR eff 1/1/2019 |
Download Form (436.23 KB) |
OR | |
| Individual Short Term Medical Enrollment Packet - UT eff 1/1/2019 |
Download Form (506.97 KB) |
UT | |
| Individual Short Term Medical Enrollment Packet - WA eff 4/1/2019 |
Download Form (363.86 KB) |
WA | |
| Individual Short Term Medical Pharmacy Reimbursement Form |
Download Form (32.81 KB) |
ID, OR, UT, WA | |
| Individual Short Term Medical Rates 4/1/2020 to 6/30/2020 - OR |
Download Form (25.18 KB) |
OR | |
| Individual Short Term Medical Rates 4/1/2020 to 6/30/2020 - UT |
Download Form (24.87 KB) |
UT | |
| Individual Short Term Medical Rates 4/1/2020 to 6/30/2020 - WA |
Download Form (24.68 KB) |
WA | |
| Individual Short Term Medical Rates 7/1/2020 to 9/30/2020 - OR |
Download Form (25.49 KB) |
OR | |
| Individual Short Term Medical Rates 7/1/2020 to 9/30/2020 - UT |
Download Form (24.95 KB) |
UT | |
| Individual Short Term Medical Rates 7/1/2020 to 9/30/2020 - WA |
Download Form (25.3 KB) |
WA | |
| Individual Vision Rider Reimbursement Form |
Download Form (33.05 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 (823.57 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| LifeMap Group Producers Incentive Program |
Download Form (458.84 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| 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 | |
| Risk Evaluation Form |
Download Form (89.29 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Short Term Disability Claim Form |
Download Form (713.67 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 | |
| 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 |