WF - New Account Questionnaire Header Image

Welcome to the New Account Questionnaire. Information submitted on this form will provide TEAM with the necessary details to set up your account. This includes information about you and your organization, the account and/or person receiving services, payroll set up, and prospective employees.  If you have any additional questions or need any assistance, please contact your dedicated Client Service Specialist, Gretchen Smith, at gsmith@teamemployer.com or 619-419-2272.


Wells Fargo Client-Level Detail

(Trust/Guardianship/Conservatorship/Agency/Estate)
Type of Account*
Account Primary Contact Name (This is the person in your organization responsible for decisions about the Account, such as the Trust Officer):*
Your/Organization's Role:*
Address*
Phone
Email
Is there another contact for the Account who serves in a formal capacity (e.g. Co- Trustee, Guardian/Conservator of the Person and/or Estate), please identify:*
Secondary Contact Name*
Phone
Email



Billing Contact Information and Instructions

Please provide the billing contact information and instructions as to where the invoice should be sent.*
Please list and separate by semi-colons (;)
Payment Method



New Account/Service Recipient Details

Name of Person/Entity Receiving Services ("Service Recipient")*
Date of Birth*
Street Address
City
State
Zip
Type of Location*
Is this residence trust-owned?*
Is there another residence where services will routinely be provided (e.g. second home, vacation property)?*
If applicable, are there any lifts or other adaptive devices in the home that help to move the Service Recipient?*



Services Provided

Nature of services provided by TEAM employees (check all that apply):*
Will Service Recipient receive regular medical intervention requiring skilled care? This information will be used to determine the advisability of involving an R.N. Care Manager.*
Use and care of feeding tube:*
Are medications given by injection?*
Use and care of catheter:*
Monitoring vital signs:*
Management and use of a ventilator*
Will TEAM employees be driving their own personal vehicle*
Will mileage be reimbursed?*
*Note that some states or localities require this type of payment and/or benefit. TEAM will advise on any specific laws that are applicable to this account.

You indicated employees would be driving a vehicle that will be supplied to them. Please provide a copy of the insurance certificate for the vehicle to TEAM at your earliest convenience.

Will employees incur and be reimbursed for other business expenses in the course and scope of their jobs*?*
*Note that some states or localities require this type of payment and/or benefit. TEAM will advise on any specific laws that are applicable to this account.
Is it expected that the employees will travel overnight with the Service Recipient in the scope of their work?*
If an entity (such as a Trust) has been paying wages to persons who will be employed by TEAM, does it have an Unemployment Insurance Account?*

Please notify the State that the Unemployment Account is no longer active once TEAM becomes the employer.




Other Account Contacts

Concerned Party/Parties: The person(s) identified will sign TEAM’s Memorandum of Understanding (MOU) and become a Joint Employer with TEAM. This is the person who chooses and has day-to-day oversight of the employees. TEAM and the Concerned Party will work together as needed to address employment issues, such as policies, job descriptions, raises, and employee performance. If there is no one in this role, please discuss with TEAM. The Concerned Party is usually either the Service Recipient (if of age and with capacity), or someone who is concerned for the well-being of and has regular contact with the Service Recipient, such as a family member, legal guardian/conservator, or close friend. If there are two people equally involved, please list both. This person should not be you (e.g. not the Trust Officer/Advisor) or an employee of Wells Fargo.

Please identify the following regarding the Concerned Party:*
Concerned Party*
Concerned Party Address*
Phone
Email
Concerned Party (Second Contact)*
Address (Second Contact)*
Phone
Email


Is there a Professional Care Manager or Case Manager for the Service Recipient?*
Care Manager/Case Manager Name*
City
State
Phone
Email
Professional Designation/Job Title:
Are there any other account contacts TEAM is authorized to speak with?



Employee Setup Information

In anticipation of hiring employees for this account TEAM requires some basic setup information including: 

  • Name
  • Relationship to Service Recipient (if applicable),
  • If they live in with the Service Recipient
  • If they are already providing services and for how long
  • Recommended Pay Rate
  • Current Pay Frequency
  • Approximate Hours Worked Per Week

If you are providing information for more than 5 employees, please complete this spreadsheet and attach it in the field below. For 5 or fewer employees, proceed to the next screen.

Please select appropriately regarding the number of employees on this account:*
No File Chosen
File uploads may not work on some mobile devices.
.csv, .xls, .xlsx file types only

Employee #1 Setup Information

Resides with Service Recipient?*
Currently working?*
Date employee began providing services:*
Current pay frequency*
Would you like to add a second employee?*

Employee #2 Setup Information

Resides with Service Recipient?*
Currently working?*
Date employee began providing services:*
Current pay frequency*
Would you like to add a third employee?*

Employee #3 Setup Information

Resides with Service Recipient?*
Currently working?*
Date employee began providing services:*
Current pay frequency*
Would you like to add a fourth employee?*

Employee #4 Setup Information

Resides with Service Recipient?*
Currently working?*
Date employee began providing services:*
Current pay frequency*
Would you like to add a fifth employee?*

Employee #5 Setup Information

Resides with Service Recipient?*
Currently working?*
Date employee began providing services:*
Current pay frequency*

Other Account Details

Timecard Approver*
Email
Are there any pre-existing or previously used written contracts or policies that outline employment terms?
Please select any paid time off policies that you are interested in TEAM adopting or developing for this account (check all that apply):
*Note that some states or localities require this type of payment and/or benefit. TEAM will advise on any specific laws that are applicable to this account.
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