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Submit a Claim

Filing a claim for insurance generally means something has gone wrong. At LifeMap we'll do our best to make the process simple and as stress free as possible so you can focus on more important things.

Use this tool to help find the appropriate claim form. Just download and fax or mail the forms to us. And don't hesitate to reach out with any questions you have along the way.

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TitleDownloadOnline FormStates
Accident Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Accidental Dismemberment Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Authorization for LifeMap to Release InformationDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Beneficiary Designation FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Critical Illness Cancer Care Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Direct Deposit Form for Claim BenefitsDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Extended Life Insurance Claim Form for EmployeeDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Extended Life Insurance Claim Form for SpouseDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Individual Critical Illness and Emergency Treatment Benefit Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Individual Short Term Medical Pharmacy Reimbursement FormDownload FormID, OR, UT, WA
Individual Vision Rider Reimbursement FormDownload FormID, OR, UT
Life Insurance Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Long Term Disability Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Short Term Disability Claim FormDownload FormAK, ID, MT, OR, UT, WA, WY
Short Term Disability Claim Form - Employee's StatementOnline Form AK, ID, MT, OR, UT, WA, WY
STM Authorization For Use and Disclosure of Protected Health InformationDownload FormID, OR, UT, WA
Vision Out of Network Reimbursement FormDownload FormAK, ID, MT, OR, UT, WA, WY
Wellness Benefit StatementDownload FormAK, CA, ID, MT, OR, UT, WA, WY

LifeMap - Dental & Vision Claims
PO Box 783
Milwaukee, WI 53201
Fax: 1(855) 733-4615

LifeMap - Long Term Disability Claims
300 Southborough Drive
Suite 200
South Portland, ME 04106-6914

Email: claims@disabilityrms.com
Fax: 1(207) 766-3448

Short Term Medical Claims
PO Box 1271 MS E8L
Portland, OR 97207-1271

Fax: 1(855) 207-1205
Email: support@lifemapco.com

All Other Claims -
Life, Accidental Death & Dismemberment, Short Term Disability, Accident, and Critical Illness

LifeMap - Claims
PO Box 1271 MS E8L
Portland, OR 97207-1271

Fax: 1(855) 733-4615
Email: claims@lifemapco.com