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Title | Download | State |
---|---|---|
Accident Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY |
Accidental Dismemberment 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 |
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 |
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 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 |
Encuentre un dentista |
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AK, CA, ID, MT, OR, UT, WA, WY |
Encuentre un oculista |
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AK, 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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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 |
Formulario de Evidencia de Asegurabilidad con Autorización HIPAA |
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AK, CA, ID, MT, OR, UT, WA, WY |
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 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 10/1/2022 to 12/31/2022 - ID |
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ID |
Individual Dental Rates 10/1/2022 to 12/31/2022 - OR |
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OR |
Individual Dental Rates 10/1/2022 to 12/31/2022 - UT |
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UT |
Individual Dental Rates 10/1/2022 to 12/31/2022 - 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 Pharmacy Reimbursement Form |
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ID, OR, UT, WA |
Individual Vision Rider Reimbursement Form |
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ID, OR, UT |
Inscribirse en el Centro Dental de LifeMap |
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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 Insurance Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY |
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 |
Long Term Disability Claim Form |
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AK, CA, ID, MT, OR, UT, WA, WY |
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 |
Short Term Disability Claim Form |
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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 |
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ID, OR, UT, WA |
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 |
Wellness Benefit Statement |
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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.
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