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.

Title Download State
Accident Claim Form PDF icon Download PDF (382.46 KB) AK, CA, ID, MT, OR, UT, WA, WY
Accidental Dismemberment Claim Form PDF icon Download PDF (339.79 KB) AK, CA, ID, MT, OR, UT, WA, WY
Affidavit of Non-State Certified Domestic Partnership PDF icon Download PDF (69.45 KB) OR
Affidavit of Non-State Registered Domestic Partnership PDF icon Download PDF (69.06 KB) WA
Affidavit of Qualified Disabled Dependent PDF icon Download PDF (116.01 KB) AK, CA, ID, MT, OR, UT, WA, WY
Affidavit of Qualifying Domestic Partnership PDF icon Download PDF (68.82 KB) AK, CA, ID, MT, UT, WY
Beneficiary Designation Form PDF icon Download PDF (60.78 KB) AK, CA, ID, MT, OR, UT, WA, WY
Critical Illness Cancer Care Claim Form PDF icon Download PDF (148.39 KB) AK, CA, ID, MT, OR, UT, WA, WY
Dental Health Article for Employees PDF icon Download PDF (91.36 KB) AK, CA, ID, MT, OR, UT, WA, WY
Dental Waiver Form PDF icon Download PDF (77.75 KB) AK, CA, ID, MT, OR, UT, WA, WY
Direct Deposit Form for Claim Benefits PDF icon Download PDF (73.49 KB) AK, CA, ID, MT, OR, UT, WA, WY
Encuentre un dentista PDF icon Download PDF (84.93 KB) AK, CA, ID, MT, OR, UT, WA, WY
Encuentre un oculista PDF icon Download PDF (58.02 KB) AK, ID, MT, OR, UT, WA, WY
Enrollment Change Form with Beneficiary Designation PDF icon Download PDF (206.09 KB) AK, CA, ID, MT, OR, UT, WA, WY
Evidence of Insurability (EOI) with HIPAA Authorization PDF icon Download PDF (577.64 KB) AK, CA, ID, MT, OR, UT, WA, WY
Extended Life Insurance Claim Form PDF icon Download PDF (163.23 KB) AK, CA, ID, MT, OR, UT, WA, WY
Formulario de Evidencia de Asegurabilidad con Autorización HIPAA PDF icon Download PDF (437.44 KB) AK, CA, ID, MT, OR, UT, WA, WY
HIPAA Authorization to Disclose Protected Health Information PDF icon Download PDF (259.78 KB) AK, CA, ID, MT, OR, UT, WA, WY
Individual Critical Illness Plus Application - ID PDF icon Download PDF (857.59 KB) ID
Individual Critical Illness Plus Application - OR PDF icon Download PDF (174.54 KB) OR
Individual Critical Illness Plus Application - WA PDF icon Download PDF (1.03 MB) WA
Individual Critical Illness Plus Beneficiary Form PDF icon Download PDF (83.93 KB) ID, OR, UT, WA
Individual Critical Illness Plus Enrollment Packet- UT PDF icon Download PDF (723.12 KB) UT
Individual Critical Illness Plus Flyer PDF icon Download PDF (112.64 KB) OR, UT, WA
Individual Critical Illness Plus Flyer - ID PDF icon Download PDF (113.27 KB) ID
Individual Dental Application - ID PDF icon Download PDF (136.36 KB) ID
Individual Dental Application - OR PDF icon Download PDF (1.13 MB) OR
Individual Dental Application - UT PDF icon Download PDF (131.54 KB) UT
Individual Dental Application - WA PDF icon Download PDF (1.22 MB) WA
Individual Dental Member Brochure - ID PDF icon Download PDF (193.48 KB) ID
Individual Dental Member Brochure - OR PDF icon Download PDF (2.2 MB) OR
Individual Dental Member Brochure - UT PDF icon Download PDF (193.42 KB) UT
Individual Dental Member Brochure - WA PDF icon Download PDF (2.2 MB) WA
Individual Dental Rates 04/01/2018 to 06/30/2018 - ID PDF icon Download PDF (333.75 KB) ID
Individual Dental Rates 04/01/2018 to 06/30/2018 - OR PDF icon Download PDF (224.39 KB) OR
Individual Dental Rates 04/01/2018 to 06/30/2018 - UT PDF icon Download PDF (339.76 KB) UT
Individual Dental Rates 04/01/2018 to 06/30/2018 - WA PDF icon Download PDF (334.22 KB) WA
Individual Dental Rates 07/01/2018 to 09/30/2018 - ID PDF icon Download PDF (172.62 KB) ID
Individual Dental Rates 07/01/2018 to 09/30/2018 - OR PDF icon Download PDF (221.89 KB) OR
Individual Dental Rates 07/01/2018 to 09/30/2018 - UT PDF icon Download PDF (178.5 KB) UT
Individual Dental Rates 07/01/2018 to 09/30/2018 - WA PDF icon Download PDF (173.88 KB) WA
Individual Short Term Medical Enrollment Packet - ID PDF icon Download PDF (509.22 KB) ID
Individual Short Term Medical Enrollment Packet - OR PDF icon Download PDF (992.36 KB) OR
Individual Short Term Medical Enrollment Packet - UT PDF icon Download PDF (446.73 KB) UT
Individual Short Term Medical Enrollment Packet - WA PDF icon Download PDF (1.17 MB) WA
Individual Short Term Medical Member Flyer PDF icon Download PDF (915.92 KB) OR, UT, WA
Individual Short Term Medical Member Flyer - ID PDF icon Download PDF (208.81 KB) ID
Individual Short Term Medical Pharmacy Reimbursement Form PDF icon Download PDF (32.81 KB) ID, MT, OR, UT, WA
Individual Short Term Medical Rates - Idaho Eff 4/1/2018 to 6/30/2018 PDF icon Download PDF (32.36 KB) ID
Individual Short Term Medical Rates - Idaho Eff 7/1/2018 to 9/30/2018 PDF icon Download PDF (166.56 KB) ID
Individual Short Term Medical Rates - Oregon Eff 4/1/2018 to 6/30/2018 PDF icon Download PDF (25.86 KB) OR
Individual Short Term Medical Rates - Oregon Eff 7/1/2018 to 9/30/2018 PDF icon Download PDF (103.62 KB) OR
Individual Short Term Medical Rates - Utah Eff 4/1/2018 to 6/30/2018 PDF icon Download PDF (26.38 KB) UT
Individual Short Term Medical Rates - Utah Eff 7/1/2018 to 9/30/2018 PDF icon Download PDF (166.13 KB) UT
Individual Short Term Medical Rates - Washington Eff 4/1/2018 to 6/30/2018 PDF icon Download PDF (55.35 KB) WA
Individual Short Term Medical Rates - Washington Eff 7/1/2018 to 9/30/2018 PDF icon Download PDF (235.13 KB) WA
Individual Vision Rider Reimbursement Form PDF icon Download PDF (33.05 KB) ID, OR, UT
Inscribirse en el Centro Dental de LifeMap PDF icon Download PDF (86.54 KB) AK, CA, ID, MT, OR, UT, WA, WY
Life Conversion Request for Information Form PDF icon Download PDF (228.07 KB) AK, CA, ID, MT, OR, UT, WA, WY
Life Insurance Claim Form PDF icon Download PDF (284.21 KB) AK, CA, ID, MT, OR, UT, WA, WY
LifeMap Advantages Beltone ID Card PDF icon Download PDF (41.49 KB) AK, CA, ID, MT, OR, UT, WA, WY
LifeMap Advantages Member Flyer PDF icon Download PDF (823.59 KB), PDF icon Download PDF (825.01 KB) AK, CA, ID, MT, OR, UT, WA, WY
Long Term Disability Claim Form PDF icon Download PDF (570.96 KB) AK, CA, ID, MT, OR, UT, WA, WY
Notice of Privacy Practices - STM, Vision, Dental PDF icon Download PDF (126.25 KB) AK, CA, ID, MT, OR, UT, WA, WY
Privacy Notice PDF icon Download PDF (24.05 KB) AK, CA, ID, MT, OR, UT, WA, WY
Short Term Disability Claim Form PDF icon Download PDF (772.04 KB) AK, ID, MT, OR, UT, WA, WY
STM Authorization For Use and Disclosure of Protected Health Information PDF icon Download PDF (129.8 KB) ID, MT, OR, UT, WA
Vision Employee Waiver Form PDF icon Download PDF (243.78 KB) AK, ID, MT, OR, UT, WA, WY
Vision Out of Network Reimbursement Form PDF icon Download PDF (293.57 KB) AK, ID, MT, OR, UT, WA, WY
Wellness Benefit Statement PDF icon Download PDF (65.09 KB) AK, CA, ID, MT, OR, UT, WA, WY