ESI Client Cancellation Form

Client Cancellation Is:*

This client cancellation is:

Effective date of cancellation:*

Effective date of cancellation:

Client ID #*

What is the Client's ID Number?

Client's Name*

Client's Name:

Reason given for cancelling our services:*

Reason given for cancelling our services?

Have you sent Bankruptcy Legal Documents to Finance?*

Legal Documents need to be sent to Barb Garfield and Jennifer Kear

If you have not sent legal documents:

If you have not sent Legal Documents:

Upload Bankruptcy Legal Documents:

Max. file size: 50 MB.

Merger Acquisition Details:*

What organization was client acquired by?

What is the other reason?*

Explain "Other" reason for cancelling services:

Contract Period:

Contract Period for Client:

Total Contract Value:*

Total contract value?

Number of EE's:*

Number of EE's:

Utilization Rate:*

Utilization Rate:

Number of Visits/Account Manager Activities Last 12 Months:*

How many visits/ Account Manager activities in the last 12 months?

Has client been with us for less than 6 months?

Number of Years as a Client:*

How many years as a client?

Client Location:*

Client Location:

Is a competitor name known?*

Do you know who the competitor is?

Competitor Name:*

If competitor name is known, please indicate:

Competitor Cost:*

How much is competitor charging?

Any Former Account Manager/s:

Were there any former account manager/s for this client?

Former Account Manager:*

Former Account Manager's Name/s:

Is there a Broker involved?*

Is there a Broker for this client?

Broker Name:*

Name of Broker

Broker Commission:

Any Account Service Issues in the past year?

What service issues did client have?

Are there open invoices on this client's account?

Are there open invoices on client's account?

Plans/Instructions for open invoices:

Additional Information:

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

Cancellation Approval

Consent*

I agree that I have discussed this with my manager and received prior authorization to submit this cancellation form.

Account Manager:*

Account Manager Name:

First Last

Account Manager Email Address*

Your email address:

ESI Client Cancellation Form

Cancellation Approval

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.

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