Life Transitions
When considering the best health insurance option for you, it's important to get personalized guidance. We can help support your employees and their family members if they may qualify for other insurance options that lower their out-of-pocket expenses. We provide the guidance to the best insurance option: 1) Retirement (eligibility due to age or disability) 2) Disability (new or existing) 3) COBRA (eligibility due to plan termination) 4) Children 18 and under (eligibility due to income guidelines) 5) Pregnancy 6) Adult dependents ages 18 to 26
Employer Group Name:
*
Submitted by:
*
First Name
Last Name
Email
*
example@example.com
Life Transition Individual: Status
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Please Select
Active
COBRA
Medicare
Badgercare
Badgercare Plus
Other
Member's Name:
*
First Name
Last Name
Member's Phone Number:
*
Please enter a valid phone number.
Member's Date of Birth:
*
-
Month
-
Day
Year
Date
Member's Email:
*
example@example.com
Member's ZIP Code:
*
Member's County:
*
Life Transition Type:
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Please Select
Medicare
COBRA
Dependent Turning Age 26
Disability
Children 18 and Under
Pregnancy
Individual Marketplace
Other
Are there any other details we should know about this inquiry?
*
Below to be filled out internally by Avergent staff.
Current Medications:
Current Plan Design:
Current Healthcare Premiums:
Submit
Should be Empty: