Form Tdi 1 – Fill Out and Use This PDF

I prefer to receive information in:

Date of Birth (Month/Day/Year): ___ /____ /______

English Spanish Portuguese

Gender: Male Female

Phone Number: __ __ __ - __ __ __ - __ __ __ __

Your e-mail address:______________________________________________________

Social Security Number: __ __ __ - __ __ - __ __ __ __

If you have recovered and/or returned to work since this illness or injury

began, please fill in dates below.

First Name:_____________________ M.:____ Last Name:__________________________

Date recovered from illness or injury:

___ /____ /______

Address:____________________________________________________________________

Date returned to work to reduced hours: ___ /____ /______

___________________________________________________________________________

Date returned to work to normal hours: ___ /____ /______

City/Town: ___________________________ State: __________

Zip: _________________

The first workday you were unable to work due to this

illness or injury: ___ /____ /______ (Note: Dates must correspond to normal work days)

During the week in which your last day of work occurred, did you work less than your normal schedule of hours?

Yes

No

If yes, indicate below the gross earnings (before taxes) for the week in which your last day of work occurred. (Our weeks run from Sun. thru Sat.)

Include overtime, vacation and sick leave pay; exclude holiday pay if you did not work the holiday.

Please indicate below, the hours worked each day during the week in which your last day of work occurred.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Total Hours

Rate of Pay

Gross Earnings

Hours

(Before taxes)

Worked

$

$

Check each day you normally work:

Sun Mon Tues Wed Thurs Fri Sat

Your normal work schedule is:

Part-time

Full-time

Total hours per week:__________

What are your gross wages (before taxes) during one normal/full work week (Sun. thru Sat.): $ __________

Please select all that applies:

Salary

Bi-weekly Hourly Per Diem On-Call Commission

MEDICAL INFORMATION

What is your illness or injury? __________________________________________________________Is this illness or injury connected to your job? Yes

No

If yes, please complete the section on the back page marked” Workers’ Compensation Information”.

Date of your medical examination for this illness/injury, closest to the unable to work date listed above: ___ /____ /______

Were you hospitalized for this disability?

Yes

No

Dates admitted to hospital: From:__________________To: _____________________

Name of Hospital:__________________________________Adress:__________________________________________________________________________

Doctor or Medical Practitioner:________________________________

Doctor or Medical Practitioner:___________________________________

Address:_____________________________________________

Address:_______________________________________________

City/Town: ___________________ State: ______ Zip: _________

City/Town: _____________________ State: ______ Zip: __________

Phone Number: __ __ __ - __ __ __ - __ __ __ __

Phone Number: __ __ __ - __ __ __ - __ __ __ __

Have you applied for or received TDI Benefits in the last 12 months?

Yes No

Have you applied for or received Unemployment Insurance Benefits in the last 12 months:

Yes No

If yes, the last week ending date you were paid from

Unemployment Insurance: __ __ /__ __ /__ __ From which state?___________

Child’s First Name

Last Name

Relationship

Birth date

Social Security Number

(natural, adopted, step

(mm/dd/yy)

(Required for children 12

or court ward)

months of age or older)

Do you have legal custody of all the children listed above?

Yes

No

Is any other person claiming your child/children as dependents under the Rhode

Do all children listed above live with you?

Yes

No

Island Temporary Disability Act? Yes No

If no, indicate name address and social security number of the person with whom

If yes, indicate the name, address and social security number of the person

they reside.

claiming such children.

Name: ________________________________________________

Name: ______________________________________________

Address:_______________________________________________

Address:______________________________________________

Social Security Number: __ __ __ /__ __ / __ __ __ __

Social Security Number: __ __ __ /__ __ / __ __ __ __

If any legal dependent named above is 18 or older, please indicate the type of

incapacity (mental or physical).

Name: _______________________Incapacity Type: ________________

Have you received any Workers’ Compensation payments for this or any other disability? Yes No

If yes, dates from: _______________to: _____________

Direct Deposit into my account

OR

Electronic Payment Card (Works like a debit card-EPC)

(You must complete the direct deposit form found in the “Forms” folder)

(You may incur fees if card is not used properly)