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 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
ADA Dental Claim Form Download PDF (915.03 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
Extended Life Insurance Claim Form Download PDF (163.23 KB) AK, CA, ID, MT, OR, UT, WA, WY
Individual Short Term Medical Pharmacy Reimbursement Form Download PDF (33.77 KB) ID, MT, OR, UT, WA
Individual Vision Rider Reimbursement Form Download PDF (33.05 KB) ID, OR, UT
Life Insurance Claim Form Download PDF (284.21 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
Short Term Disability Claim Form Download PDF (998.87 KB) AK, ID, MT, OR, UT, WA, WY
STM Authorization For Use and Disclosure of Protected Health Information Download PDF (129.8 KB) ID, MT, OR, UT, WA
Vision Out of Network Reimbursement Form Download PDF (293.57 KB) ID, MT, OR, UT, WA, WY
Wellness Benefit Statement Download PDF (65.09 KB) AK, CA, ID, MT, OR, UT, WA, WY