State Hawaii Tdi 45 Form PDF Details

In the eyes of workers and employers alike in Hawaii, understanding the process for filing a disability claim is essential, and the State Hawaii TDI-45 form plays a pivotal role in this procedure. Provided by Pacific Guardian Life Insurance Co., Ltd., this form is a comprehensive document designed to collect detailed information from the claimant, the employer, and the attending physician to support a claim for disability benefits. The form outlines a clear three-step process for filing: firstly, obtaining and completing the claimant's statement in Part A, including personal and employment-related details alongside an explanation of the disability; secondly, having the employer fill out Part B, providing necessary employment verification and opinion about the disability's relation to the job; and thirdly, obtaining a medical evaluation from a doctor who completes Part C. The form also emphasizes timely submission—within 90 days of the onset of disability—to prevent delays in benefit processing. Additionally, it underscores inclusivity, ensuring that discrimination on the basis of race, color, sex, and other identifiers does not influence the submission or processing of a claim. This meticulous collection and presentation of information ensure that all parties involved have a clear understanding of the circumstances surrounding the disability claim, thus facilitating a smoother benefits claim process.

QuestionAnswer
Form NameState Hawaii Tdi 45 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshawaii tdi forms, form tdi 45 hawaii, tdi form hawaii, hawaii guardian 45 form

Form Preview Example

PACIFIC GUARDIAN LIFE INSURANCE CO., LTD.

1440 KAPIOLANI BOULEVARD, SUITE 1700

HONOLULU, HAWAII 96814

PHONE: 942-1282 FAX: 942-1284

CLAIM FOR DISABILITY BENEFITS

INSTRUCTIONS FOR FILING A CLAIM FOR DISABILITY BENEFITS

RESET FORM

Step 1. Obtain a claim form (TDI-45) from your employer.

Step 2. Answer all questions in Part A. Claimant’s Statement. Make sure you sign your name, or if you are unable to, have a responsible person sign for you. To avoid unnecessary delay, present your claim form to your employer no later than 90 days after you are unable to perform the duties of your job. If you file beyond 90 days, attach a statement explaining why you were unable to file earlier. After you file your claim, your employer or employer’s insurance carrier will notify you if you are eligible for benefits.

Step 3. Have your employer complete and sign Part B. Employer’s Statement

Step 4. Have your doctor complete and sign Part C. Doctor’s Statement. Have your doctor mail this form to the insurance carrier listed, unless otherwise directed by your employer in Part A (22) or Part B (13).

It is the policy of the Department of Labor and Industrial Relations that no person shall on the basis of race, color, sex, marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation, and National Guard participation be subjected to discrimination, excluded from participation in, or denied the benefits of the department’s services, programs, activities, or employment.

PART A - CLAIMANT’S STATEMENT

1.

My name is: (First, Middle, Last) Type or print

2.

Social Security Number

 

3.

Birth Date

 

 

 

 

 

 

 

4.

Mailing address: (Street, City or Town, State, Zip Code)

5.

Telephone Number

6.

7.

 

 

 

 

 

o Male

 

o Single

 

 

 

 

o Female

 

o Married

 

 

 

 

 

 

 

DISABILITY INFORMATION

8.My disability was caused by: Describe (if accident, give date, place and circumstances) o Sickness

oAccident

9.

The first day I was unable to perform the duties of my job:

10.

Was this disability caused by your job?

 

 

 

 

 

 

 

o Yes

o No

o Unknown

 

 

(month)

(day)

(year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

o I have not recovered from my disability.

12.

o I have not returned to work.

 

 

o I have recovered from my disability.

 

 

 

o I have returned to work.

 

 

Date recovered:

 

 

 

 

Date returned:

 

 

 

EMPLOYMENT INFORMATION

13.

My present employer is: (or last employer, if unemployed)

 

14.

Prior to my disability, I worked for this employer:

 

 

 

 

 

(Name and address - include street, city, state, zip code)

 

 

 

 

 

From:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

I worked:

 

 

 

 

 

 

 

hours per week

 

 

 

 

 

 

 

 

 

 

and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I earned $

 

 

 

 

 

per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Occupation:

 

17.

I am a union member.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Yes

 

Name of union:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

Other Hawaii employers I worked for during the past 52 weeks:

 

 

 

 

 

 

 

Period of Employment

 

 

 

 

Weekly

 

 

 

 

 

 

 

 

From

 

 

 

 

 

 

To

 

Hours

Wages

Employer name and address

 

 

Month

Day

Year

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

Does your employer have a printed TDI notice posted and maintained conspicuously in your employment area?

 

 

 

o Yes

o No

 

 

 

 

 

Did your employer inform you of your entitlement to TDI benefits?

 

 

 

 

 

 

 

 

 

 

 

 

 

o Yes

o No

 

 

 

 

 

Did your employer provide you this claim form when you first requested it for this disability?

 

 

 

 

 

 

 

 

o Yes

o No

 

 

 

 

OTHER BENEFITS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. In addition to TDI benefits, I am receiving or claiming benefits from the following: (Check those that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Federal Disability Insurance Benefits

o Unemployment Insurance Benefits

 

 

 

 

 

 

 

 

 

 

o Workers’ Compensation Benefits

o Damages for Personal Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Employer’s Sick Leave Plan

o Other (Health and Welfare Fund; Union Plan, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

During the 52 weeks (year) before my disability began, I have received TDI benefits for other periods of disability

 

o Yes

 

 

 

o No

 

 

 

 

 

If yes, from whom

 

 

 

From

 

 

 

 

 

 

 

 

 

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. Mail the doctor’s statement to the insurance carrier unless otherwise indicated here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby claim Temporary Disability Benefits and certify that the foregoing statements including any accompanying statements are true and complete to the best of my knowledge.

Claimant’s signature

E-mail address

Date

 

 

 

Representative’s signature, if claimant is unable to sign

Print representative’s name

Relationship

 

 

 

Form TDI-45 (Rev. 10/09)

_____% PREMIUM PAID BY EMPLOYER

PART B - EMPLOYER’S STATEMENT

IMPORTANT: To enable your disabled employee to receive TDI benefits within 10 days as required by law, it is imperative that you complete the following information for prompt submittal to your insurance carrier.

1.

Claimant’s Name

 

 

 

2.

Claimant’s Occupation

 

 

 

 

 

 

 

 

3. Employer Department of Labor No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Group and Account Number

 

 

5. Firm or Trade Name

 

 

 

 

 

6. Business Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

In reporting wage information below, use gross wages, which include wages and all other

8.

Worked:

 

 

o Full-time

 

 

o Part-time

 

remuneration such as commissions, bonuses, tips and the cash value of meals, lodging, etc.

 

 

 

Date hired:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Answer either A, B, or C.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(month)

 

(day)

(year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date last worked prior to disability:

 

 

 

 

 

 

 

 

A. If claimant was paid on a salary basis, enter claimant’s weekly or monthly salary earned

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

in the last week or month prior to the date claimant’s disability began:

 

 

 

 

 

 

 

 

 

 

(month)

 

(day)

(year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If returned to work, give date:

 

 

 

 

 

 

 

 

 

 

Week $ ______________

Month $ ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(month)

 

(day)

(year)

 

B. If paid on an hourly basis, give rate per hour $ _____________. Enter the weekly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Check days normally worked:

 

 

 

 

 

 

 

 

 

 

earnings for the past 8 weeks prior to the date disability began, including the last

 

 

 

 

 

 

 

 

 

 

 

 

o Sun o

 

Mon

o Tues o Wed o

Thurs o Fri o Sat

 

date worked. (Include reported tips)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If on rotation, give the number of days worked per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekending

 

 

 

 

 

 

 

10.

Enter the following for the last 52 weeks prior to the date the

Week

 

 

 

 

 

No. Days

 

Gross

No.

Month

 

Day

Year

 

Worked

 

Amount

 

 

employee’s disability began:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Calendar

 

 

No. of

 

No. of Hours

 

Total Wages

 

 

 

 

 

 

 

 

 

 

 

 

 

Quarter Ending

 

Weeks Worked

 

Worked Per Wk.

 

Earned

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

 

 

11.

Do you think this disability was caused by the claimant’s job?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Yes

o No

o Unknown

 

 

 

 

 

 

 

Total

XXXX

 

XXXX

XXXX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was an Employer’s Report of Industrial Injury WC-1 filed?

 

C. If claimant received any or all earnings on a commission or piecework basis, enter these

 

 

 

 

 

o Yes

o No

 

 

 

 

 

 

 

 

 

 

 

 

earnings for the last 52 weeks prior to the date claimant’s disability began:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This covers the period:

 

 

 

 

 

 

 

 

 

 

 

If yes, advise name and address of Worker’s Compensation Carrier

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: ______________ through ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(month/day/year)

(month/day/year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earnings: $ ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Mail the doctor’s statement to:

 

 

 

 

 

 

 

12.

Has or will this employee receive all or any portion of the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

period of disability covered by this claim?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wages?

o Yes

o No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary?

o Yes

o No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sick leave pay?

o Yes

o No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vacation pay?

o Yes

o No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separation pay?

o Yes

o No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, show period:

 

 

 

 

 

 

Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

 

 

 

 

 

(mo/day/yr)

 

$_________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Through:

 

 

 

 

 

 

(mo/day/yr)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that the above information is true and complete to the best of my knowledge.

Signature of employer or employer’s representative

Title

Date

E-mail address

Telephone No.

Fax No.

PART C - DOCTOR’S STATEMENT

IMPORTANT: Please complete and mail within 7 working days after examination to the insurance carrier listed above unless otherwise directed in Part A (22) or Part B (13).

1.

Claimant’s Name

 

 

 

 

 

2. Age

3.

Sex

 

 

 

 

 

 

 

 

 

4.

Physical requirements of claimant’s occupation as related by claimant:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

If pregnancy, advise expected date of birth __________________________________. If disability is pregnancy with complications, advise complications above.

 

 

 

 

 

 

 

 

 

 

7.

Was claimant’s disability caused by claimant’s employment?

o Yes

o No

 

 

 

 

If yes, was Physician’s Report WC-2 filed? o Yes o No

If yes, filed with _____________________________________________________________

 

 

 

 

 

 

 

 

 

 

8.

Was claimant hospitalized?

o Yes

o No

If yes, from ______________________ to ______________________

 

 

 

 

Surgery indicated?

o Yes

o No

Type _____________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Complete the following:

 

 

 

 

 

 

Month

 

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

Date of your first treatment of this disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First date claimant unable to perform the duties of employment (see #4 above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of your most recent treatment of this disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date claimant will be able to perform usual work (estimate) (DO NOT use “undetermined” or “unknown”) (See #4 above)

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Are you referring claimant to another physician?

o Yes

o No

If yes, give name ____________________________________________________

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

Was claimant referred to you?

 

 

o Yes

o No

If yes, give name ____________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that the above information is true and complete to the best of my knowledge.

Doctor’s name (Please print)

Office Address

Doctor’s signature

Date

Telephone No.

Fax No.

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1. When filling out the tdi 45 form, ensure to complete all needed blank fields within the associated form section. It will help speed up the process, making it possible for your details to be processed efficiently and accurately.

pacific guardian tdi form completion process described (portion 1)

2. When this part is done, go on to type in the relevant information in all these - Occupation, Other Hawaii employers I worked, Employer name and address a b c d, I am a union member, o Yes Name of union, o No, From, Hours Wages, Period of Employment, Weekly, Month Day Year, Month Day Year, Does your employer have a printed, Did your employer inform you of, and o No o No o No.

pacific guardian tdi form completion process outlined (step 2)

It is easy to make an error when filling out your Did your employer inform you of, thus you'll want to take another look prior to when you finalize the form.

3. In this part, have a look at Mail the doctors statement to the, I hereby claim Temporary, Claimants signature, Email address, Date, Representatives signature if, Print representatives name, Relationship, and Form TDI Rev. Each one of these have to be taken care of with greatest precision.

The right way to fill out pacific guardian tdi form portion 3

4. This fourth subsection comes next with the next few fields to look at: PREMIUM PAID BY EMPLOYER, PART B EMPLOYERS STATEMENT, IMPORTANT To enable your disabled, Claimants Name, Claimants Occupation, Employer Department of Labor No, Group and Account Number, Firm or Trade Name, Business Address, In reporting wage information, Worked o Fulltime, o Parttime, remuneration such as commissions, Date hired, and month day year.

Step # 4 for filling in pacific guardian tdi form

5. Finally, this final section is precisely what you'll have to complete before using the document. The blanks at issue include the following: Total, XXXX, XXXX, XXXX, C If claimant received any or all, earnings for the last weeks prior, From through, monthdayyear, monthdayyear, Earnings, Mail the doctors statement to, Do you think this disability was, o Yes o No o Unknown, Was an Employers Report of, and If yes advise name and address of.

Completing section 5 in pacific guardian tdi form

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