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| Title | Download | State |
|---|---|---|
| Accident Claim Form |
 Download PDF (382.46 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Accidental Dismemberment Claim Form |
Download PDF (339.79 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Affidavit of Non-State Certified Domestic Partnership |
Download PDF (69.45 KB) |
OR |
| Affidavit of Non-State Registered Domestic Partnership |
Download PDF (69.06 KB) |
WA |
| Affidavit of Qualified Disabled Dependent |
Download PDF (77.92 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Affidavit of Qualifying Domestic Partnership |
Download PDF (68.82 KB) |
AK, CA, ID, MT, UT, WY |
| Assignment of Life Insurance Proceeds Form for Life Claim Benefits |
Download PDF (194.5 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Beneficiary Designation Form |
Download PDF (60.78 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Critical Illness Cancer Care Claim Form |
Download PDF (148.39 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Dental Health Article for Employees |
Download PDF (91.36 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Dental Waiver Form |
Download PDF (77.75 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Direct Deposit Form for Claim Benefits |
Download PDF (73.49 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Encuentre un dentista |
Download PDF (84.93 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Encuentre un oculista |
Download PDF (58.02 KB) |
AK, ID, MT, OR, UT, WA, WY |
| Evidence of Insurability (EOI) with HIPAA Authorization |
Download PDF (78.87 KB) |
AK, ID, MT, OR, UT, WA, WY |
| Extended Life Insurance Claim Form |
Download PDF (163.23 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Formulario de Evidencia de Asegurabilidad con Autorización HIPAA |
Download PDF (437.44 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| HIPAA Authorization to Disclose Protected Health Information |
Download PDF (259.78 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Individual Critical Illness Plus Application - ID |
Download PDF (857.59 KB) |
ID |
| Individual Critical Illness Plus Application - OR |
Download PDF (174.54 KB) |
OR |
| Individual Critical Illness Plus Application - WA |
Download PDF (1.03 MB) |
WA |
| Individual Critical Illness Plus Beneficiary Form |
Download PDF (83.93 KB) |
ID, OR, UT, WA |
| Individual Critical Illness Plus Enrollment Packet- UT |
Download PDF (723.12 KB) |
UT |
| Individual Critical Illness Plus Flyer |
Download PDF (112.64 KB) |
OR, UT, WA |
| Individual Critical Illness Plus Flyer - ID |
Download PDF (113.27 KB) |
ID |
| Individual Dental Application - ID |
Download PDF (136.36 KB) |
ID |
| Individual Dental Application - OR |
Download PDF (1.13 MB) |
OR |
| Individual Dental Application - UT |
Download PDF (131.54 KB) |
UT |
| Individual Dental Application - WA |
Download PDF (1.22 MB) |
WA |
| Individual Dental Member Brochure - ID |
Download PDF (193.48 KB) |
ID |
| Individual Dental Member Brochure - OR |
Download PDF (2.2 MB) |
OR |
| Individual Dental Member Brochure - UT |
Download PDF (193.42 KB) |
UT |
| Individual Dental Member Brochure - WA |
Download PDF (2.2 MB) |
WA |
| Individual Dental Rates 4/1/2020 to 6/30/2020 - ID |
Download PDF (28.12 KB) |
ID |
| Individual Dental Rates 4/1/2020 to 6/30/2020 - OR |
Download PDF (31.74 KB) |
OR |
| Individual Dental Rates 4/1/2020 to 6/30/2020 - UT |
Download PDF (38.78 KB) |
UT |
| Individual Dental Rates 4/1/2020 to 6/30/2020 - WA |
Download PDF (29.06 KB) |
WA |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - ID |
Download PDF (28.16 KB) |
ID |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - OR |
Download PDF (31.78 KB) |
OR |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - UT |
Download PDF (38.81 KB) |
UT |
| Individual Dental Rates 7/1/2020 to 9/30/2020 - WA |
Download PDF (29.14 KB) |
WA |
| Individual Short Term Medical Enrollment Packet - OR eff 1/1/2019 |
Download PDF (436.23 KB) |
OR |
| Individual Short Term Medical Enrollment Packet - UT eff 1/1/2019 |
Download PDF (506.97 KB) |
UT |
| Individual Short Term Medical Enrollment Packet - WA eff 4/1/2019 |
Download PDF (363.86 KB) |
WA |
| Individual Short Term Medical Pharmacy Reimbursement Form |
Download PDF (32.81 KB) |
ID, OR, UT, WA |
| Individual Short Term Medical Rates 4/1/2020 to 6/30/2020 - OR |
Download PDF (25.18 KB) |
OR |
| Individual Short Term Medical Rates 4/1/2020 to 6/30/2020 - UT |
Download PDF (24.87 KB) |
UT |
| Individual Short Term Medical Rates 4/1/2020 to 6/30/2020 - WA |
Download PDF (24.68 KB) |
WA |
| Individual Short Term Medical Rates 7/1/2020 to 9/30/2020 - OR |
Download PDF (25.49 KB) |
OR |
| Individual Short Term Medical Rates 7/1/2020 to 9/30/2020 - UT |
Download PDF (24.95 KB) |
UT |
| Individual Short Term Medical Rates 7/1/2020 to 9/30/2020 - WA |
Download PDF (25.3 KB) |
WA |
| Individual Vision Rider Reimbursement Form |
Download PDF (33.05 KB) |
ID, OR, UT |
| Inscribirse en el Centro Dental de LifeMap |
Download PDF (86.54 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Life Conversion Request for Information Form |
Download PDF (228.07 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Life Insurance Claim Form |
Download PDF (284.21 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| LifeMap Advantages Beltone ID Card |
Download PDF (41.49 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| LifeMap Advantages Member Flyer |
Download PDF (823.57 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Long Term Disability Claim Form |
Download PDF (570.96 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Notice of Privacy Practices - STM, Vision, Dental |
Download PDF (126.25 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Privacy Notice |
Download PDF (24.05 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
| Short Term Disability Claim Form |
Download PDF (713.67 KB) |
AK, ID, MT, OR, UT, WA, WY |
| Short Term Disability Claim Form - Employee's Statement | AK, ID, MT, OR, UT, WA, WY | |
| STM Authorization For Use and Disclosure of Protected Health Information |
Download PDF (129.8 KB) |
ID, OR, UT, WA |
| Vision Employee Waiver Form |
Download PDF (243.78 KB) |
AK, ID, MT, OR, UT, WA, WY |
| Vision Out of Network Reimbursement Form |
Download PDF (293.57 KB) |
AK, ID, MT, OR, UT, WA, WY |
| Wellness Benefit Statement |
Download PDF (65.09 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |
Use this tool to help find the appropriate form. Simply select the audience that best fits you and the state you or your company resides in. If you are an employee covered under a group plan with LifeMap, you are a group plan member and don’t need to select a state. Feel free to reach out to us with any questions you have along the way.