ESI Client Cancellation Form Client Cancellation Is:*This client cancellation is: Please SelectEEP Only!Effective Immediately - ALL ESI staff will be notified upon submission to cancel client servicesTo be processed on a future dateEffective 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?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?*Legal Documents need to be sent to Barb Garfield and Jennifer KearHave you sent them?Yes-I have sent Legal DocumentsNo-I will send Legal Documents or Upload BelowIf you have not sent legal documents:If you have not sent Legal Documents: Upload Bankruptcy 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?Has client been with us for less than 6 months?Please selectNoYesNumber 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?Please selectNoYesCompetitor 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?Please selectNoYesFormer Account Manager:*Former Account Manager's Name/s: Is there a Broker involved?*Is there a Broker for this client?Please SelectNoYesBroker Name:*Name of Broker Broker Commission:Broker Commission: Any Account Service Issues in the past year?Any Account Service Issues in the past year?Please SelectNoYesWhat service issues did client have?What service issues did client have? Are there open invoices on this client's account?Are there open invoices on client's account?Please SelectNoYesPlans/Instructions for open invoices:Plans/Instructions for open invoices: Additional Information:Is 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:*Account Manager Name: First Last Account Manager Email Address*Your email address: