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.
| Title | Download | Online Form | States |
|---|---|---|---|
| Accident Claim Form | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Accidental Dismemberment Claim Form | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Authorization for LifeMap to Release Information | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Beneficiary Designation Form | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Critical Illness Cancer Care Claim Form | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Direct Deposit Form for Claim Benefits | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Extended Life Insurance Claim Form for Employee | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Extended Life Insurance Claim Form for Spouse | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Individual Critical Illness and Emergency Treatment Benefit Claim Form | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Individual Short Term Medical Pharmacy Reimbursement Form | Download Form | ID, OR, UT, WA | |
| Individual Vision Rider Reimbursement Form | Download Form | ID, OR, UT | |
| Life Insurance Claim Form | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Long Term Disability Claim Form | Download Form | AK, CA, ID, MT, OR, UT, WA, WY | |
| Short Term Disability Claim Form | Download Form | 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 | ID, OR, UT, WA | |
| Vision Out of Network Reimbursement Form | Download Form | AK, ID, MT, OR, UT, WA, WY | |
| Wellness Benefit Statement | Download Form | AK, CA, ID, MT, OR, UT, WA, WY |
Individual Plan Members
Group Plan Members
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