- Individual Dental Plans
- Explore Group Plans
- Members
- All Members
- Individual Plan Members
- Group Plan Members
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 | Online Form | State |
|---|---|---|---|
| Accident Claim Form |
 Download Form (382.46 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Accidental Dismemberment Claim Form |
Download Form (339.79 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| ADA Dental Claim Form |
Download Form (1.12 MB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Assignment of Life Insurance Proceeds Form for Life Claim Benefits |
Download Form (194.5 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Critical Illness Cancer Care Claim Form |
Download Form (148.39 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Direct Deposit Form for Claim Benefits |
Download Form (88.72 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Extended Life Insurance Claim Form for Employee |
Download Form (301.28 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Extended Life Insurance Claim Form for Spouse |
Download Form (291.73 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Individual Critical Illness and Emergency Treatment Benefit Claim Form |
Download Form (877.17 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Individual Short Term Medical Pharmacy Reimbursement Form |
Download Form (32.81 KB) |
ID, OR, UT, WA | |
| Individual Vision Rider Reimbursement Form |
Download Form (143.95 KB) |
ID, OR, UT | |
| Life Insurance Claim Form |
Download Form (284.21 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Long Term Disability Claim Form |
Download Form (570.96 KB) |
AK, CA, ID, MT, OR, UT, WA, WY | |
| Short Term Disability Claim Form |
Download Form (803.12 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Short Term Disability Claim Form - Employee's Statement | Online Form | AK, ID, MT, OR, UT, WA, WY | |
| STM Authorization For Use and Disclosure of Protected Health Information |
Download Form (129.8 KB) |
ID, OR, UT, WA | |
| Vision Out of Network Reimbursement Form |
Download Form (293.57 KB) |
AK, ID, MT, OR, UT, WA, WY | |
| Wellness Benefit Statement |
Download Form (65.09 KB) |
AK, CA, ID, MT, OR, UT, WA, WY |