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TMG USE ONLY - LEGACY INTAKE FORM
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Associate Name
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First
Last
Preferred Pronouns
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She/Her
He/Him
They/Them
Other (please indicate in the notes section)
Personal Email
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Work Email
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Phone Number
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Current Title
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Work Location (City, State)
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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)
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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?
*
Employee Only
Employee + Spouse
Employee + Children
Family
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?
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Yes
No
Additional Notes
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Intake Completed By
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Home
Benefits
Health Insurance
Dental Insurance
Vision Insurance
Life Insurance
401(K) Retirement Planning
Flexible Spending Account
Discount Offers
Other Perks
FAQs
HR Team
Forms
Associate Forms
Management Forms