Sold Account Form - ESI Group

"*" indicates required fields

Client Type*

Client Type *

ESL

Medical Mutual

Paramount

Medical Mutual Information:

Medical Mutual Base Group Number*

Medical Mutual Base Group Number

Funding Type*

Funding Type *

Medical Mutual Sales Contact*

Medical Mutual Sales Contact *

First Last

Is ESI EAP directly billing the group?*

Is ESI EAP directly billing the group? *

Yes (this will be the default)

Other *

Other*

*For alternative billing arrangements, please include Medical Mutual accounting in the discussion.

Account Manager Details:

Account Manager Name*

Account Manager Name *

First Last

Account Manager Email*

Account Manager Email *

Employee ID Number*

Employee ID Number *

Client Retention*

Client Retention *

This client can be reassigned

I need to retain this client

Is the commission being split?*

Is the commission being split? *

Yes

Sales Rep Commission Rate*

Sales Rep Commission Rate *

Other Account Manager Name*

Who are you splitting the commission with? *

First Last

Other Employee ID Number*

Please enter their Employee ID Number *

Your Commission Rate*

Your Commission Rate *

Other Account Manager Commission Rate*

Other Account Manager Commission Rate *

New Client Information:

Client's Legal Name*

Client's Legal Name *

Does the client go by another name?*

Does the client go by another name? *

Yes

What other name does the client go by?*

What other name does the client go by? *

Client Address*

Client Address *

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

Number of Employees*

Number of Employees *

Industry*

Industry *

Contract/Billing Information:

Contract Start Date*

Contract Start Date *

Contract End Date*

Contract End Date *

PEPY or Flat Rate*

PEPY or Flat Rate *

Total Contract Value*

Total Contract Value *

Brand*

Brand *

# of Sessions*

# of Sessions *

# of Trainings*

# of Trainings *

# of Traumas*

# of Traumas *

SAP Fee*

SAP Fee *

Billing Terms*

Billing Terms *

Is the billing contact different than the primary contact?

Is the billing contact different than the primary contact? *

Yes

Billing Contact's Name*

Billing Contact's Name *

Billing Contact's Title

Billing Contact's Email Address*

Billing Contact's Email Address *

Billing Contact's Phone Number

Is the billing address different?

Is the billing address different? *

Yes

Client's Billing Address*

Client's Billing Address

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

Send Invoice to:

Send Invoice to (name and department):

Special Billing Instructions

Contact Information:

Primary Contact Name*

Primary Contact Name *

First Last

Primary Contact Title*

Primary Contact Title *

Primary Contact Email*

Primary Contact Email *

Primary Contact Phone Number*

Primary Contact Phone Number *

Do you need to add a secondary contact?*

Do you need to add a secondary contact?

Yes

Secondary Contact Name*

Secondary Contact Name *

First Last

Secondary Contact Title

Secondary Contact Email*

Secondary Contact Email *

Secondary Contact Phone Number

Is secondary contact's address the same as in EAPX?*

Is secondary contact's address the same as in EAPX? *

Yes

Secondary Contact Address*

Secondary Contact 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

#2 Secondary Contact Name*

#2 Secondary Contact Name *

First Last

#2 Secondary Contact Title

#2 Secondary Contact Email*

#2 Secondary Contact Email *

#2 Secondary Contact Phone Number

Is #2 secondary contact's address the same as in EAPX?*

Is #2 secondary contact's address the same as in EAPX? *

Yes

#2 Secondary Contact Address*

#2 Secondary Contact Address *

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

Broker Information:

Is there a Broker?*

Is there a Broker?

Yes

Broker Org Name*

Broker Org Name *

Broker Contact Name*

Broker Contact Name *

First Last

Broker Email Address*

Broker Email Address *

Broker Phone Number

Broker Address*

Broker Address *

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

Broker Commission Structure

No Commission

20% Year 1 - 5% Renewals

40% Year 1 - 5% Renewals

Not Sure

Do you want the broker contact to receive client/member communications?*

Do you want the broker contact to receive client/member communications? *

Yes

Broker Notes

Materials:

Send Hardcopy Materials to Client?*

Send Hardcopy Materials to Client?

Yes

Do you need Spanish materials?*

Do you need Spanish materials? *

Yes

Quantity (Spanish)*

Quantity (Spanish) *

Should materials be shipped to the address that is listed in EAPX?*

Should materials be shipped to the address that is listed in EAPX? *

Yes

Ship Materials to:*

What Address should materials be shipped to? *

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

Ship Materials to Attention:

Special Instructions for Materials:

Are there any special instructions for sending materials?

Email Communications:

Intro Email and Maintenance*

Intro Email and Maintenance *

Yes - Send Intro Email - Email addresses have been provided.

No - Do not send intro email - Add to Maintenance only.

No - Do not send intro email or add to Maintenance.

Date to send Intro Email*

Date to send Intro Email *

Document Upload:

Do you have the census file?*

Do you have the census file? *

Yes

Coming soon

Census File*

Census File *

Drop files here or

Max. file size: 50 MB.

Does the client offer health insurance?*

Does the client offer health insurance? *

Yes, I need to upload a document

Yes, I need to enter it manually

Health Insurance Questionnaire*

Health Insurance Questionnaire *

Drop files here or

Max. file size: 50 MB.

Health Insurance Plan Info*

Health Insurance Plan Info *

Accounting Related Notes*

Accounting Related Notes

Medical Mutual Information:

Account Manager Details:

New Client Information:

Contract/Billing Information:

Contact Information:

Broker Information:

Materials:

Email Communications:

Document Upload:

6 Important Reasons to Upgrade to an ESI EAP

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