The State Hawaii TDI 45 form is a claim for disability benefits that individuals must complete to receive financial assistance when they are unable to work due to a medical condition. This form requires input from the claimant, their employer, and their doctor to ensure a thorough evaluation of the claim. To get started on your claim, fill out the TDI 45 form by clicking the button below.
The State of Hawaii's TDI 45 form is essential for those seeking temporary disability benefits due to illness or injury. This form, officially known as the Claim for Disability Benefits, outlines the process for filing a claim. It consists of three main parts: the Claimant's Statement, the Employer's Statement, and the Doctor's Statement. Claimants must provide personal information, details about their disability, and employment history in Part A. They are required to submit the form within 90 days of becoming unable to work. Employers complete Part B, verifying the claimant's employment status and earnings. Meanwhile, Part C is filled out by a medical professional, confirming the nature of the disability and its impact on the claimant's ability to work. Timely submission of all sections is crucial for a smooth claims process, as it helps ensure that individuals receive the benefits they need without unnecessary delays. The TDI 45 form also emphasizes the importance of non-discrimination, ensuring that all claimants are treated fairly regardless of their background.
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.
Name of union:
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
a.
b.
c.
d.
19.
Does your employer have a printed TDI notice posted and maintained conspicuously in your employment area?
Did your employer inform you of your entitlement to TDI benefits?
Did your employer provide you this claim form when you first requested it for this disability?
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
If yes, from whom
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.
Claimant’s Name
Claimant’s Occupation
3. Employer Department of Labor No.
4. Group and Account Number
5. Firm or Trade Name
6. Business Address
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.
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:
If returned to work, give date:
Week $ ______________
Month $ ______________
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
Enter the following for the last 52 weeks prior to the date the
Week
No. Days
Gross
No.
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
Do you think this disability was caused by the claimant’s job?
Total
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
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)
Earnings: $ ______________
Mail the doctor’s statement to:
Has or will this employee receive all or any portion of the
period of disability covered by this claim?
Wages?
Salary?
Sick leave pay?
Vacation pay?
Separation pay?
If yes, show period:
(mo/day/yr)
$_________
Through:
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
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).
2. Age
Sex
Physical requirements of claimant’s occupation as related by claimant:
Diagnosis:
If pregnancy, advise expected date of birth __________________________________. If disability is pregnancy with complications, advise complications above.
Was claimant’s disability caused by claimant’s employment?
If yes, was Physician’s Report WC-2 filed? o Yes o No
If yes, filed with _____________________________________________________________
Was claimant hospitalized?
If yes, from ______________________ to ______________________
Surgery indicated?
Type _____________________________________________________________
Complete the following:
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)
Are you referring claimant to another physician?
If yes, give name ____________________________________________________
OR
Was claimant referred to you?
Doctor’s name (Please print)
Office Address
Doctor’s signature
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