ࡱ> >@=k  bjbj "}}lDDD8|    $    "     P޵O2D" 0 kk Seminar Scheduling Information To our Valued Customer: Below are some items of information that will help us to begin the scheduling process for you. This information will allow us to learn more about your company and get an idea of the types of services that will best meet your needs. Please complete as much of the form as possible and return it to the Employer Service Coordinator to schedule an event. There are three ways to return this form or the information requested by it: e-mail to  HYPERLINK "mailto:esh.comments@cignabehavioral.com" esh.comments@cignabehavioral.com, fax to 952-996-2702 or mail to Employer Service Coordinator, 11095 Viking Drive, Suite 350, Eden Prairie, MN 55344. Please note that we request a minimum of four weeks notice when scheduling an event. This enables us to schedule an appropriate, prepared, well-qualified provider for your on-site training. Thank you and we look forward to serving you in the future. Company Information Company name: Site contact and phone number: Contact Email: Site address: Number of employees on site: Type of business: Would you like a phone consultation with the Employer Service Coordinator to assist in selecting a topic? If so, what is a good time to reach you? Seminar Specifics Topic wanted: Number of sessions wanted: Number of participants anticipated per session: General audience type (i.e. managers/employees/supervisors): Preferred dates, days, or times, if any: Current issues at the site, if any: * Please note that cancellations or changes made with less than 2 full business days notice will be billed to the Employer Service Hours for your company. Feel free to add any additional questions, comments, or specifications below:  CIGNA Behavioral Health, Inc. is a CIGNA HealthCare company. CIGNA HealthCare" refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by such subsidiaries, including Connecticut General Life Insurance Company, Intracorp*, CIGNA Behavioral Health, Inc., and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc., and not by CIGNA Corporation. 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