ESI Client Cancellation Form Client Cancellation Is:*Please SelectGCN Only!Effective Immediately - ALL ESI staff will be notified upon submission to cancel client servicesTo be processed on a future dateEffective date of cancellation:*Client ID #*Client's Name*Reason given for cancelling our services:*Please SelectBankruptcyCorporate Parent MandateCovid-19Financial/CutbacksFree EAPHR ChangeLow UtilizationMerger/AcquisitionNo CommunicationNon-PaymentWent with competitor, lower pricesWent with competitor, service issuesOtherHave you sent Bankruptcy Legal Documents to Finance?*Please SelectYes-I have sent Legal DocumentsNo-I will send Legal Documents or Upload BelowIf you have not sent legal documents:Upload Bankruptcy Legal Documents:Max. file size: 50 MB.Organization acquired by:*What is the other reason?*Is a competitor name known?*Please selectNoYesCompetitor Name:*Competitor Cost:*Contract Period:*Total Contract Value:*Number of EE's:*Utilization Rate:*Number of Significant contacts in the last 12 Months:**Significant contacts include meetings with HR/primary contact, benefit overviews, web or Training Center demos, trainings or health fairs, etc. This can be virtual or on-site.Has client been with us for less than 6 months?*Please selectNoYesNumber of Years as a Client:*Client Location:*Any Former Account Manager/s:Please selectNoYesFormer Account Manager:*Is there a Broker involved?*Please SelectNoYesBroker Name:*Broker Commission:Any Account Service Issues in the past year?Please SelectNoYesWhat service issues did client have?Are there open invoices on this client's account?Please SelectNoYesWhat is the plan for open invoice/s?*Please SelectLeave invoice/s open - Payment still expectedWrite-off invoice/s - No payment is expectedIs there any additional information you would like to include regarding this cancellation?Cancellation ApprovalConsent* I agree that I have discussed this with my manager and received prior authorization to submit this cancellation form.Account Manager:* First Last Account Manager Email Address*