Legacy Intake Form

TMG USE ONLY - LEGACY INTAKE FORM

* Indicates required field

Associate Name *

First

Last

Preferred Pronouns *

Personal Email *

Work Email *

Phone Number *

Current Title *

Work Location (City, State) *

Current Scheduled Work Hours *

Current Paid Time Off Allotment (total days) *

If yes, which days you have requested off? *

Are you currently enrolled in insurance benefits with Wells Fargo? (please select all that apply) *

Not currently enrolled Enrolled in Medical - Copay Plan with HRA Enrolled in Medical - Higher Use HSA Enrolled in Medical - Lower Use HSA Enrolled in Medical - Kaiser HMO Enrolled in Standard Dental Enrolled in Enhanced Dental Enrolled in Vision

If you are currently enrolled in medical insurance with Wells Fargo, which plan you are enrolled in? *

If you are not currently enrolled in Wells Fargo medical insurance, would you be interested in joining TMG's medical insurance for the 2023 calendar year? *

Additional Notes *

Intake Completed By *

First

Last

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