Jump to content You are here Home / Employers / Submit a Claim Submit a Claim Claim Forms I am a(n) - Any - Individual Plan Member Group Plan Member Title Download Online Form State 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 ADA Dental Claim Form Download Form AK, CA, ID, MT, OR, UT, WA, WY Assignment of Life Insurance Proceeds Form for Life Claim Benefits 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 Critical Illness Plus Beneficiary Form Download Form ID, OR, UT, WA 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 (link is external) 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 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. EMPLOYER ADMIN Make a Payment Submit a Claim Request Enrollment Change Login to Accounts Help for Employers QUICK LINKS Find a Form Small Groups (2-25 Employees) Go to Employer Admin Center Go to Dental Center Group Administration Guide Group Dental ID Card Replacement LifeMap - Dental & Vision Claims PO Box 783 Milwaukee, WI 53201 LifeMap – Long Term Disability Claims 300 Southborough Drive Suite 200 South Portland, ME 04106-6914 Email: claims@disabilityrms.com (link sends e-mail) Fax: 1(207) 766-3448 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 (link sends e-mail) Member Dashboard Find a Provider Submit a Claim Make a Payment Get Member Advantages Employer Dashboard Make a Payment Submit a Claim Find a Form Login to Accounts Request Enrollment Change Producer Dashboard Individual Business Small Group Business Large Group Business (26+ Employees) Get Appointed For Individual Policies: 1(800) 756-4105 For Group Policies: 1(800) 794-5390 For Claims: 1(800) 286-1129 Connect with us About LifeMap News Careers Contact Us © 2019 LifeMap Assurance Company® All Rights Reserved Terms of Use Privacy Policy California Consumer Privacy Act (link is external) Disclosures Non-discrimination Español