Client and Contact Change Form

Sales Rep*

Type of Change*

Type of Change

Contact
Address
Client Name

Client Name*

Does this change apply to additional verticals/accounts or only the one named above?*

Does this change apply to additional verticals/accounts or only the one named above? (changes that are different between verticals/accounts need to be submitted separately)

Additional Verticals/Accounts
Only named account below

Additional verticals/accounts to change (separate multiple accounts with a comma)*

Old Name*

New Name*

Alias

Does this affect billing/who gets invoices?*

Does this affect billing/who gets invoices?

Yes
No

Does this affect all contacts?*

Does this affect all contacts?

Yes
No

** Do a contact change so you can specify who the address update is for.

Update Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is changing?*

What is changing?

Adding New Primary Contact
Adding New Secondary Contact
Removing a Secondary only
Update an existing contact's info (enter name and only info that is changing)
Adding a new broker
Changing a broker

Previous Broker Name

Broker Name

New Broker Name

Broker Address

Street Address Address Line 2 City State ZIP Code

Broker Phone

Broker E-mail Address

Do you want this broker to receive communications?*

Do you want this broker to receive communications?

Yes
No

Is there a broker contract in place already?

Yes
No

Do we need a broker contract?

Yes
No

Are they getting a commission?

Yes
No

What is the commission percentage? (enter the number only)

Is update for primary or secondary contact?*

Is update for primary or secondary contact?

Primary
Secondary

Original Name*

New Name

Title

Update Office Phone

Update Cell Phone

Update Fax

Update Email

Update Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is current primary contact no longer with company?*

Is current primary contact no longer with company?

No longer an employee
Still with company, move to secondary contact
Still with company, not in contact role (won't be in EAPX, but could be in a communication program)

Is this brand new primary or move from secondary*

Is this a brand new primary contact or are you moving a secondary contact to primary?

New Primary Contact
Move a secondary to primary

New Primary Contact Name*

New Primary Contact Name

Title

Office Phone

Cell Phone

Fax Phone

Email*

Is current primary address listed in EAPX correct?*

Is current primary address listed in EAPX correct?

Yes
No

Address*

New Primary Contact address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reason for change?*

Reason for change?

Just adding a new secondary contact
Replacing an existing secondary contact

Remove Secondary Contact Name*

Remove Secondary Contact Name

Remove Secondary E-mail

Is secondary contact no longer with the company?*

Is secondary contact no longer with the company?

No longer an employee
Still with company, not in contact role (won't be in EAPX, but could be in a communication program)

New Secondary Name*

New Secondary Name

Secondary Title

Secondary Phone

Secondary Cell

Secondary Fax

Secondary Email*

Address same as primary in EAPX?*

Is address same as primary in EAPX?

Yes
No

Secondary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you need to add another secondary contact?*

Do you need to add another secondary contact?

Yes
No

Do you need to remove another secondary contact?*

Do you need to remove another secondary contact?

Yes
No

Secondary Name #2*

Secondary Name #2

Secondary #2 Title

Secondary #2 Phone

Secondary #2 Cell

Secondary #2 Fax

Secondary #2 Email*

Is secondary contact no longer with the company?*

Is secondary contact no longer with the company?

No longer an employee
Still with company, not in contact role (won't be in EAPX, but could be in a communication program)

Is this contact address same as primary in EAPX?*

Is this contact address same as primary in EAPX?

Yes
No

Secondary #2 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you need to add a 3rd secondary contact?*

Do you need to add a 3rd secondary contact?

Yes
No

Do you need to remove a 3rd secondary contact?*

Do you need to remove a 3rd secondary contact?

Yes
No

Secondary #3 Name*

Secondary #3 Name

Secondary #3 Title

Secondary #3 Phone

Secondary #3 Cell

Secondary #3 Fax

Secondary #3 Email*

Is secondary contact no longer with the company?*

Is secondary contact no longer with the company?

No longer an employee
Still with company, not in contact role (won't be in EAPX, but could be in a communication program)

Is 3rd contact at same address as primary?*

Is 3rd contact at same address as primary?

Yes
No

Secondary #3 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Change Form

To better serve you, please choose an option below:

I am a current employee/family member of ESI EAP seeking services for myself

I represent an employer seeking a quote from ESI EAP for an organization.

Help for Employees

5 Reasons to Upgrade your EAP to an ESI EAP