ESI Client Cancellation Form

Client Cancellation Is:*

Effective date of cancellation:*

Client ID #*

Client's Name*

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:*

What is the other reason?*

Is a competitor name known?*

Competitor 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?*

Number of Years as a Client:*

Client Location:*

Any Former Account Manager/s:

Former Account Manager:*

Is there a Broker involved?*

Broker Name:*

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?

What is the plan for open invoice/s?*

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:*

First Last

Account Manager Email Address*

ESI Client Cancellation Form

Cancellation Approval

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