New Group Sign Up

NEW GROUP SIGN UP

This form is intended for new employer groups signing 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.

EAP New Group Sign Up

General Information

First Name

Last Name

Title

Email Address

Phone

DBA Company Name

Legal Company Name (If different from above)

Address (Please be sure to include Street, City, State, and Zip)

Accounts Payable

Accounts Payable Name

Title

Phone

Company and Benefits

Industry Type

Number of eligible employees

Eligibility Criteria

All Employees Benefit Eligible Employees Only Other

Eligibility Criteria: Other

Multiple Locations

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.

Health Insurance

EAP Services

Contact your Customer Success Manager (CSM) for pricing questions.

Additional EAP Services

LifeBalance Discount Program Enlight

Broker Information

Brokerage Company

Broker Name

Address (Please be sure to include Street, City, State, and Zip)

Phone

Account Manager

Account Manager Phone

Account Manager Email

Date Renewal information is due to Broker

Renewal information will be sent 90 days prior to renewal unless otherwise requested.

Additional Information

Please share any additional information