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)

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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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