Bridgeworks Sign Up This form is intended for BridgeWorks sign up with Canopy EAP. If you found this form by mistake or need assistance with signing up a new group please email info@canopywell.com or call 800-433-2320.
BridgeWorks Sign Up Your Email Address (required)• We will not send unsolicited email nor share your email address with anyone. Ever. General Information(required)• First Name (required)• M.I. Last Name (required)• (required)• Title(required)• Phone(required)• DBA Company Name(required)• Legal Company Name (If different from above) Address (Please be sure to include Street, City, State, and Zip)(required)• Accounts Payable(required)• Accounts Payable Name(required)• Title(required)• Phone(required)• Email(required)• Company and Benefits(required)• Industry Type(required)• --- Auto / Transportation Business Services Construction Consumer Services Education Financial Fire Food and Beverage Health Hospitality Insurance / Benefits Law Firms Manufacturing Media Non-Profit Public Retail Retirement Strategic Partner Technology Unspecified Number of eligible employees(required)• Eligibility Criteria(required)• All Employees Benefit Eligible Empoyees Only Other Eligibility Criteria:If you answered "other" please provide additional information Eligibility Criteria: Other Multiple Locations(required)• Yes, we have multiple locations No, we only have one location If you answered "yes" please provide the city and state of each location in the "locations" section below. Or you may email your account manager your list. Locations (required)• Health Insurance(required)• EAP Services Contact your Customer Success Manager for pricing questions. Additional EAP Services 3 Sessions ($3.10) 6 Sessions ($3.60) Additional Information Please share any additional information Preferred Start Date(required)• Please Don't Enter Anything In This Space