ESI Client Cancellation Form

"*" indicates required fields

Client Cancellation Is:*

Effective Date of Cancellation:*

Client ID #*

Client's Name*

GCN Value*

Reason given for cancelling our services:*

Have you sent Bankruptcy Legal Documents to Finance?*

If you have not sent legal documents:

Upload Bankruptcy Legal Documents:

Max. file size: 50 MB.

Organization acquired by:*

Please describe Service or Other Issue:*

Is there a competitor?*

Is a competitor name known?*

Competitor Name:*

Competitor Cost:*

Current Contract Start Date*

Current Contract End Date*

Total Contract Value:*

Number of EE's:*

Have you had this client less than 6 months?*

Is there a Former Account Executive:

Former Account Executive:*

Client Location:*

Is there a Broker involved?*

Brokerage Firm Name:*

Are there open invoices on this client's account?*

What is the plan for open invoice/s?*

Invoices will be left open for 30 days before being closed.

Is there any additional information you would like to include regarding this cancellation?

Your Name:*

First Last

Your Email Address*