Employer Notification - Transition Counts Form

Complete this form to notify the Transition Counts Team of an employee transitioning from current employment status.

Name of Organization*

Please provide the name of the employer
Name*
First Last
Please provide the name of the employee that is changing employment status
Date of Status Change*
MM slash DD slash YYYY

When did (or when will) the employee's employment status change?
Employee's Address*
Street Address City State / Province / Region ZIP / Postal Code

Please provide the employee's address so we know where to mail the information on the Transition Counts program .
Employee's Phone Number*
What is the best contact number for the employee?
Current Plan Participation:*
- Medical
- Dental
- Vision
- Disability
- Critical Illness/Accident
- Life
- Retirement
- Other (please specify below)
What is the employee currently enrolled in?
Additional Comments:
Please provide any additional information relevant to this employee's employment transition.
Name
This field is for validation purposes and should be left unchanged.