Please note: The state field refers to the location where your employer is headquartered.

Title Download Online Form State
Accident Claim Form PDF icon Download Form (382.46 KB) AK, CA, ID, MT, OR, UT, WA, WY
Accidental Death & Dismemberment Employee Flyer PDF icon Download Form (1.99 MB) AK, CA, MT, OR, UT, WA, WY
Accidental Death & Dismemberment Employee Flyer - ID PDF icon Download Form (1.99 MB) ID
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 (915.03 KB) AK, CA, ID, MT, OR, UT, WA, WY
Affidavit of Non-State Certified Domestic Partnership PDF icon Download Form (69.45 KB) OR
Affidavit of Non-State Registered Domestic Partnership PDF icon Download Form (69.06 KB) WA
Affidavit of Qualified Disabled Dependent PDF icon Download Form (116.01 KB) AK, CA, ID, MT, OR, UT, WA, WY
Affidavit of Qualifying Domestic Partnership PDF icon Download Form (68.82 KB) AK, CA, ID, MT, UT, WY
Agent Standard Commission Schedule - Alaska PDF icon Download Form (950.69 KB) AK
Agent Standard Commission Schedule - MT PDF icon Download Form (953.75 KB) MT
Agent Standard Commission Schedule - OR, ID, UT PDF icon Download Form (958.14 KB) ID, OR, UT
Agent Standard Commission Schedule - WA PDF icon Download Form (955.2 KB) WA
Agent Standard Commission Schedule - WY PDF icon Download Form (951.57 KB) WY
Beneficiary Designation Form PDF icon Download Form (60.78 KB) AK, CA, ID, MT, OR, UT, WA, WY
Billing FAQ PDF icon Download Form (325.67 KB) AK, CA, ID, MT, OR, UT, WA, WY
Cancer Only Critical Illness Employee Flyer PDF icon Download Form (2.04 MB) AK, MT, OR, UT, WA, WY
Cancer Only Critical Illness Employee Flyer - ID PDF icon Download Form (2.04 MB) ID
Cancer Plus Critical Illness Employee Flyer PDF icon Download Form (2.17 MB) AK, MT, OR, UT, WA, WY
Cancer Plus Critical Illness Employee Flyer - ID PDF icon Download Form (2.17 MB) ID
Critical Illness Cancer Care Claim Form PDF icon Download Form (148.39 KB) AK, CA, ID, MT, OR, UT, WA, WY
Dental Health Article for Employees PDF icon Download Form (91.36 KB) AK, CA, ID, MT, OR, UT, WA, WY
Dental Overview for Employers 2-299 PDF icon Download Form (232.16 KB) AK, MT, OR, UT, WA, WY
Dental Overview for Employers 300+ PDF icon Download Form (189.4 KB) AK, MT, OR, UT, WA, WY
Dental Overview for ID Employers 2-299 PDF icon Download Form (232.99 KB) ID
Dental Overview for ID Employers 300+ PDF icon Download Form (189.99 KB) ID
Dental Voluntary Group Employee Flyer PDF icon Download Form (2.16 MB) AK, MT, OR, UT, WA, WY
Dental Waiver Form PDF icon Download Form (77.75 KB) AK, CA, ID, MT, OR, UT, WA, WY
Direct Deposit Form for Claim Benefits PDF icon Download Form (73.49 KB) AK, CA, ID, MT, OR, UT, WA, WY
Dollar-Based Dental for Employees PDF icon Download Form (90.6 KB) OR, UT, WA
Dollar-Based Dental for Employees - ID PDF icon Download Form (1.76 MB) ID
Dollar-Based Dental for Employers PDF icon Download Form (89.53 KB) OR, UT, WA
Dollar-Based Dental for Idaho Employers PDF icon Download Form (89.79 KB) ID
Employer Admin Center User Guide and FAQ PDF icon Download Form (1.47 MB) AK, CA, ID, MT, OR, UT, WA, WY
Employer Admin Guide - Traditional PDF icon Download Form (106.17 KB) AK, CA, ID, MT, OR, UT, WA, WY
Evidence of Insurability (EOI) with HIPAA Authorization PDF icon Download Form (78.87 KB) Online Form AK, ID, MT, OR, UT, WA, WY
Express Group Basic Life and ADD Benefit Summary PDF icon Download Form (92.89 KB) AK, ID, MT, OR, UT, WA, WY
Express Group Basic Life and ADD Plan Options PDF icon Download Form (75.1 KB) AK, ID, MT, OR, UT, WA, WY
Express Group Dental Benefit Summary PDF icon Download Form (72.39 KB) ID, OR, UT, WA
Express Group Dental Benefit Summary for WA PDF icon Download Form (83.46 KB) WA
Express Group Dental Plan Options PDF icon Download Form (91.74 KB) ID, OR, UT, WA
Express Group Dental Plan Options for WA PDF icon Download Form (82.41 KB) WA
Express Group Implementation Worksheet (2-9) PDF icon Download Form (176.83 KB) AK, CA, ID, MT, OR, UT, WA, WY
Express Group LTD Benefit Summary PDF icon Download Form (74.03 KB) AK, ID, MT, OR, UT, WA, WY
Express Group STD Benefit Summary PDF icon Download Form (75.68 KB) AK, ID, MT, OR, UT, WA, WY
Express Group Vision Benefit Summary PDF icon Download Form (78.44 KB) AK, ID, MT, OR, UT, WA, WY
Express Group Vision Plan Options PDF icon Download Form (73.96 KB) AK, ID, MT, OR, UT, WA, WY
Express Group Voluntary Life and ADD Benefit Summary PDF icon Download Form (76.88 KB) AK, ID, MT, OR, UT, WA, WY
Express Group Voluntary Life and ADD Plan Options PDF icon Download Form (76.56 KB) AK, ID, MT, OR, UT, WA, WY
Express Groups 2-9 Service Directory PDF icon Download Form (33.92 KB) AK, CA, ID, MT, OR, UT, WA, WY
Express Groups STD and LTD Plan Options PDF icon Download Form (77.31 KB) AK, 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
Find a Dentist PDF icon Download Form (82.62 KB) AK, CA, ID, MT, OR, UT, WA, WY
Find a Vision Provider - Group PDF icon Download Form (185.93 KB) AK, ID, MT, OR, UT, WA, WY
Group Dental Employee Flyer PDF icon Download Form (1.59 MB) AK, CA, MT, OR, UT, WA, WY
Group Dental Employee Flyer - ID PDF icon Download Form (1.59 MB) ID
Group Products Overview 10+ PDF icon Download Form (760.88 KB) AK, MT, OR, UT, WA, WY
Group Products Overview 10+ CA PDF icon Download Form (2.3 MB) CA
Group Products Overview 10+ ID PDF icon Download Form (763.5 KB) ID
Group Products Overview Express 2-9 CA PDF icon Download Form (1.16 MB) CA
HIPAA Authorization to Disclose Protected Health Information PDF icon Download Form (259.78 KB) AK, CA, ID, MT, OR, UT, WA, WY
Individual Critical Illness Plus Application - ID PDF icon Download Form (857.59 KB) ID
Individual Critical Illness Plus Application - OR PDF icon Download Form (174.54 KB) OR
Individual Critical Illness Plus Application - WA PDF icon Download Form (1.03 MB) WA
Individual Critical Illness Plus Beneficiary Form PDF icon Download Form (83.93 KB) ID, OR, UT, WA
Individual Critical Illness Plus Enrollment Packet- UT PDF icon Download Form (723.12 KB) UT
Individual Critical Illness Plus Flyer PDF icon Download Form (112.64 KB) OR, UT, WA
Individual Critical Illness Plus Flyer - ID PDF icon Download Form (113.27 KB) ID
Individual Dental Application - ID PDF icon Download Form (136.36 KB) ID
Individual Dental Application - OR PDF icon Download Form (1.13 MB) OR
Individual Dental Application - UT PDF icon Download Form (131.54 KB) UT
Individual Dental Application - WA PDF icon Download Form (1.22 MB) WA
Individual Dental Member Brochure - ID PDF icon Download Form (193.48 KB) ID
Individual Dental Member Brochure - OR PDF icon Download Form (2.2 MB) OR
Individual Dental Member Brochure - UT PDF icon Download Form (193.42 KB) UT
Individual Dental Member Brochure - WA PDF icon Download Form (2.2 MB) WA
Individual Dental Rates 1/01/2019 to 3/31/2019 - ID PDF icon Download Form (127.85 KB) ID
Individual Dental Rates 1/01/2019 to 3/31/2019 - OR PDF icon Download Form (141.44 KB) OR
Individual Dental Rates 1/01/2019 to 3/31/2019 - UT PDF icon Download Form (133.96 KB) UT
Individual Dental Rates 1/01/2019 to 3/31/2019 - WA PDF icon Download Form (128.91 KB) WA
Individual Dental Rates 10/01/2018 to 12/31/2018 - ID PDF icon Download Form (127.67 KB) ID
Individual Dental Rates 10/01/2018 to 12/31/2018 - OR PDF icon Download Form (141.57 KB) OR
Individual Dental Rates 10/01/2018 to 12/31/2018 - UT PDF icon Download Form (132.62 KB) UT
Individual Dental Rates 10/01/2018 to 12/31/2018 - WA PDF icon Download Form (128.68 KB) WA
Individual Short Term Medical Enrollment Packet - ID eff 1/1/2019 PDF icon Download Form (358.33 KB) ID
Individual Short Term Medical Enrollment Packet - ID through 12/31/18 PDF icon Download Form (358.18 KB) ID
Individual Short Term Medical Enrollment Packet - OR eff 1/1/2019 PDF icon Download Form (319.51 KB) OR
Individual Short Term Medical Enrollment Packet - OR through 12/31/18 PDF icon Download Form (322.36 KB) OR
Individual Short Term Medical Enrollment Packet - UT eff 1/1/2019 PDF icon Download Form (412.41 KB) UT
Individual Short Term Medical Enrollment Packet - UT through 12/31/18 PDF icon Download Form (408.46 KB) UT
Individual Short Term Medical Member Flyer PDF icon Download Form (915.92 KB) OR, UT
Individual Short Term Medical Member Flyer - ID PDF icon Download Form (208.81 KB) ID
Individual Short Term Medical Pharmacy Reimbursement Form PDF icon Download Form (32.81 KB) ID, MT, OR, UT, WA
Individual Short Term Medical Rates - Idaho Eff 1/1/2019 to 3/31/2019 PDF icon Download Form (24.75 KB) ID
Individual Short Term Medical Rates - Idaho Eff 10/1/2018 to 12/31/2018 PDF icon Download Form (87.88 KB) ID
Individual Short Term Medical Rates - Oregon Eff 1/1/2019 to 3/31/2019 PDF icon Download Form (33.72 KB) OR
Individual Short Term Medical Rates - Oregon Eff 10/1/2018 to 12/31/2018 PDF icon Download Form (87.85 KB) OR
Individual Short Term Medical Rates - Utah Eff 1/1/2019 to 3/31/2019 PDF icon Download Form (33.6 KB) UT
Individual Short Term Medical Rates - Utah Eff 10/1/2018 to 12/31/2018 PDF icon Download Form (86.59 KB) UT
Individual Vision Rider Reimbursement Form PDF icon Download Form (33.05 KB) ID, OR, UT
Initial Premium Invoice PDF icon Download Form (195.62 KB) AK, CA, ID, MT, OR, UT, WA, WY
Life Conversion Request for Information Form PDF icon Download Form (228.07 KB) AK, CA, ID, MT, OR, UT, WA, WY
Life Employee Flyer PDF icon Download Form (2.15 MB) AK, CA, MT, OR, UT, WA, WY
Life Insurance Claim Form PDF icon Download Form (284.21 KB) AK, CA, ID, MT, OR, UT, WA, WY
Life Insurance Worksheet PDF icon Download Form (142.3 KB) AK, CA, MT, OR, UT, WA, WY
Life Insurance Worksheet - Idaho PDF icon Download Form (141.89 KB) ID
LifeMap Advantages Beltone ID Card PDF icon Download Form (41.49 KB) AK, CA, ID, MT, OR, UT, WA, WY
LifeMap Advantages Member Flyer PDF icon Download Form (823.57 KB) AK, CA, ID, MT, OR, UT, WA, WY
LifeMap Group Producers Incentive Program PDF icon Download Form (458.84 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
Long Term Disability Employee Flyer PDF icon Download Form (2.09 MB) AK, CA, MT, OR, UT, WA, WY
Long Term Disability Employee Flyer - ID PDF icon Download Form (2.09 MB) ID
Notice of Privacy Practices - STM, Vision, Dental PDF icon Download Form (126.25 KB) AK, CA, ID, MT, OR, UT, WA, WY
Privacy Notice PDF icon Download Form (24.05 KB) AK, CA, ID, MT, OR, UT, WA, WY
Provider EFT Enrollment Form PDF icon Download Form (225.17 KB) AK, CA, ID, MT, OR, UT, WA, WY
Risk Evaluation Form PDF icon Download Form (89.29 KB) AK, CA, ID, MT, OR, UT, WA, WY
Short Term Disability Claim Form PDF icon Download Form (772.04 KB) AK, ID, MT, OR, UT, WA, WY
Short Term Disability Overview for Employers PDF icon Download Form (486.03 KB) AK, MT, OR, UT, WA, WY
Short Term Disability Overview for ID Employers PDF icon Download Form (486.52 KB) ID
STM Authorization For Use and Disclosure of Protected Health Information PDF icon Download Form (129.8 KB) ID, MT, OR, UT, WA
Vision Employee Flyer PDF icon Download Form (1.31 MB) AK, MT, OR, UT, WA, WY
Vision Employee Flyer - ID PDF icon Download Form (1.31 MB) ID
Vision Employee Waiver Form PDF icon Download Form (243.78 KB) AK, ID, MT, OR, UT, WA, WY
Vision Out of Network Reimbursement Form PDF icon Download Form (293.57 KB) AK, ID, MT, OR, UT, WA, WY
Voluntary Accident Employee Flyer PDF icon Download Form (3.09 MB) AK, MT, OR, UT, WA, WY
Voluntary Accident Employee Flyer - ID PDF icon Download Form (3.09 MB) ID
Voluntary Accidental Death & Dismemberment Employee Flyer PDF icon Download Form (1.99 MB) AK, MT, OR, UT, WA, WY
Voluntary Accidental Death & Dismemberment Employee Flyer - ID PDF icon Download Form (1.99 MB) ID
Voluntary Group Dental Employee Flyer PDF icon Download Form (1.09 MB) AK, MT, OR, UT, WA, WY
Voluntary Group Dental Employee Flyer - ID PDF icon Download Form (2.41 MB) ID
Voluntary Life Employee Flyer PDF icon Download Form (2.16 MB) AK, MT, OR, UT, WA, WY
Voluntary Life Employee Flyer ID PDF icon Download Form (2.16 MB) ID
Voluntary Long Term Disability Employee Flyer PDF icon Download Form (260.77 KB) AK, MT, OR, UT, WA, WY
Voluntary Long Term Disability Employee Flyer - ID PDF icon Download Form (261.1 KB) ID
Voluntary Short Term Disability Employee Flyer PDF icon Download Form (1.33 MB) AK, MT, OR, UT, WA, WY
Voluntary Short Term Disability Employee Flyer - ID PDF icon Download Form (1.33 MB) ID
Wellness Benefit Statement PDF icon Download Form (65.09 KB) AK, CA, ID, MT, OR, UT, WA, WY