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Accident Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Accidental Dismemberment Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
ADA Dental Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Affidavit of Non-State Certified Domestic PartnershipDownload FormOR
Affidavit of Non-State Registered Domestic PartnershipDownload FormWA
Affidavit of Qualified Disabled DependentDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Affidavit of Qualifying Domestic PartnershipDownload FormAK, CA, ID, MT, UT, WY
Agent Standard Commission Schedule - AKDownload FormAK
Agent Standard Commission Schedule - CADownload FormCA
Agent Standard Commission Schedule - MT, WYDownload FormMT, WY
Agent Standard Commission Schedule - OR, ID, UTDownload FormID, OR, UT
Agent Standard Commission Schedule - WADownload FormWA
Assignment of Life Insurance Proceeds Form for Life Claim BenefitsDownload 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
Billing FAQDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Critical Illness Cancer Care Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Dental Waiver FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Direct Deposit Form for Claim BenefitsDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Employer Admin Center User Guide and FAQDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Employer Admin GuideDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Encuentre un dentistaDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Encuentre un oculistaDownload FormAK, ID, MT, OR, UT, WA, WY
Evidence of Insurability (EOI) Frequently Asked QuestionsDownload FormAK, ID, MT, OR, UT, WA, WY
Evidence of Insurability (EOI) with HIPAA AuthorizationDownload FormOnline Form AK, 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
Find a DentistDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Find a Vision Provider - GroupDownload FormAK, ID, MT, OR, UT, WA, WY
Folleto de accidente para empleadosDownload FormID, MT, OR, UT, WA, WY
Formulario de Evidencia de Asegurabilidad con Autorización HIPAADownload FormAK, CA, ID, MT, OR, UT, WA, WY
HIPAA Authorization to Disclose Protected Health InformationDownload 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 Dental Rates 7/1/2023 to 9/30/2023 - IDDownload FormID
Individual Dental Rates 7/1/2023 to 9/30/2023 - ORDownload FormOR
Individual Dental Rates 7/1/2023 to 9/30/2023 - UTDownload FormUT
Individual Dental Rates 7/1/2023 to 9/30/2023 - WADownload FormWA
Individual Short Term Medical Pharmacy Reimbursement FormDownload FormID, OR, UT, WA
Individual Vision Rider Reimbursement FormDownload FormID, OR, UT
Initial Premium InvoiceDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Inscribirse en el Centro Dental de LifeMapDownload FormAK, CA, ID, MT, OR, UT, WA, WY
La hoja de trabajo del seguro de vidaDownload FormAK, CA, ID, MT, OR, UT, WA, WY
La hoja de trabajo del seguro por discapacidadDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Life Conversion Request for Information FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Life Insurance Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
LifeMap Enrollment Change FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
LifeMap Protect 10 Benefit SummaryDownload FormID, OR, UT, WA
LifeMap Protect 20 Benefit SummaryDownload FormID, OR, UT, WA
LifeMap Protect 30 Benefit SummaryDownload FormID, OR, UT, WA
LifeMap Protect Plans FlyerDownload FormID, OR, UT, WA
Long Term Disability Claim FormDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Notice of Privacy Practices - STM, Vision, DentalDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Privacy NoticeDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Regence Life Solutions Life 10 Benefit SummaryDownload FormID, OR, UT, WA
Regence Life Solutions Life 20 Benefit SummaryDownload FormID, OR, UT, WA
Regence Life Solutions Life 30 Benefit SummaryDownload FormID, OR, UT, WA
Risk Evaluation 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
Small Group (10-25 Employees) Basic Life and AD&D Benefit SummaryDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (10-25 Employees) Dental Plan J Benefit SummaryDownload FormID, OR, UT, WA
Small Group (10-25 Employees) Dental Plan K and L Benefit SummaryDownload FormID, OR, UT, WA
Small Group (10-25 Employees) Dental Plan OptionsDownload FormID, OR, UT
Small Group (10-25 Employees) LTD Benefit SummaryDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (10-25 Employees) Master ApplicationDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Small Group (10-25 Employees) STD Benefit SummaryDownload FormAK, ID, MT, OR, UT, WY
Small Group (10-25 Employees) Voluntary Life and AD&D Benefit SummaryDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (10-25 Employees) Washington Dental Plan Options (Active PPO Plans)Download FormWA
Small Group (10-25 Employees) Washington Dental Plan Options (Passive PPO Plans)Download FormWA
Small Group (2-25 Employees) Implementation WorksheetDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Small Group (2-25 Employees) Service DirectoryDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Small Group (2-25 Employees) Vision Benefit Summary - $130 Frame AllowanceDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (2-25 Employees) Vision Benefit Summary - $150 Frame AllowanceDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (2-25 Employees) Washington Dental Plan L with TMJ Benefit SummaryDownload FormWA
Small Group (2-9 Employees) Basic Life and AD&D Benefit SummaryDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (2-9 Employees) Dental Plan A Benefit SummaryDownload FormID, OR, UT
Small Group (2-9 Employees) Dental Plan C Benefit SummaryDownload FormID, OR, UT
Small Group (2-9 Employees) Dental Plan OptionsDownload FormID, OR, UT
Small Group (2-9 Employees) LTD Benefit SummaryDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (2-9 Employees) Master ApplicationDownload FormAK, CA, ID, MT, OR, UT, WA, WY
Small Group (2-9 Employees) STD Benefit SummaryDownload FormAK, ID, MT, OR, UT, WY
Small Group (2-9 Employees) Voluntary Life and AD&D Benefit SummaryDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group (2-9 Employees) Washington Dental Plan J Benefit SummaryDownload FormWA
Small Group (2-9 Employees) Washington Dental Plan K Benefit SummaryDownload FormWA
Small Group (2-9 Employees) Washington Dental Plan L Benefit SummaryDownload FormWA
Small Group (2-9 Employees) Washington Dental Plan OptionsDownload FormWA
Small Group (5-9 Employees) Washington Dental Plan L with Ortho Benefit SummaryDownload FormWA
Small Group Basic Life and AD&D Plan OptionsDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group LTD Plan OptionsDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group STD Plan OptionsDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group Vision Plan OptionsDownload FormAK, ID, MT, OR, UT, WA, WY
Small Group Voluntary Life and AD&D Plan OptionsDownload FormAK, ID, MT, OR, UT, WA, WY
STM Authorization For Use and Disclosure of Protected Health InformationDownload FormID, OR, UT, WA
Vision Employee Waiver FormDownload FormAK, ID, MT, OR, UT, WA, WY
Vision Out of Network Reimbursement FormDownload FormAK, ID, MT, OR, UT, WA, WY
VSP VisionDownload Form
Wellness Benefit StatementDownload FormAK, CA, ID, MT, OR, UT, WA, WY

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