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How to Apply for a Dental Plan

There are now 2 ways to enroll in the LifeMap Individual Dental Plan:

1. Online Enrollment

To Enroll On-Line, enter your zip code and then click on the “Enroll” button.

2. Print and Mail Enrollment Forms

  • Choose the dental insurance plan that best meets your needs.
  • Click here to download the application. Print and complete the application in full. Missing information may cause your effective date to be delayed. If you have more than four dependents, please attach a separate list.
  • If you are enrolling a non-registered certified domestic partner, please complete the attached affidavit.
  • Calculate the premium. Indicate if you are enrolling for the Optional Vision coverage. Be sure to select a monthly or quarterly payment schedule. Include the applicable payment for the first month or quarter of coverage, according to the payment schedule you have selected.
  • You may enroll for Child Only coverage. If you are enrolling children only, a separate application must be completed and submitted for each child.
  • If you have any questions, please call toll-free 1-800-756-4105.
  • Send the application and your check or money order made payable to LifeMap Assurance Company to:
    LifeMap Assurance Company
    PO Box 1271, MS E-3A
    Portland, OR 97207-1271


If you are not satisfied with this Policy, you may return the policy within 10 days of delivery for a full refund of premium. An additional ten percent penalty will be added to any premium refund due that is not paid within 30 days of return of the Policy to the insurer or insurance producer.

Please read your policy carefully and keep it available for future reference.