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.

Claim Forms

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

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
ADA Dental Claim Form PDF icon Download PDF (915.03 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
Extended Life Insurance Claim Form PDF icon Download PDF (163.23 KB) AK, CA, ID, MT, OR, UT, WA, WY
Individual Critical Illness Plus Beneficiary Form PDF icon Download PDF (83.93 KB) ID, OR, UT, WA
Individual Short Term Medical Pharmacy Reimbursement Form PDF icon Download PDF (32.81 KB) ID, MT, OR, UT, WA
Individual Vision Rider Reimbursement Form PDF icon Download PDF (33.05 KB) ID, OR, UT
Life Insurance Claim Form PDF icon Download PDF (284.21 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
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 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