The State Hawaii TDI 45 form is an essential document for workers in Hawaii seeking to claim Temporary Disability Insurance (TDI) benefits due to an inability to work because of a disability. It outlines a step-by-step process requiring information from the claimant, their employer, and their doctor to be properly filled and submitted within specific guidelines. For a streamlined process to access disability benefits and ensure timely submission, it's crucial to fill out and submit the TDI 45 form as guided. Click the button below to start filling out your form.
In the beautiful state of Hawaii, ensuring the well-being and support of its workforce is a priority, exemplified by the comprehensive State Hawaii TDI-45 form provided by Pacific Guardian Life Insurance Co., Ltd. This form is a crucial tool for employees navigating the challenging times that come with injury or sickness that prevents them from performing their job duties. It outlines a thorough process divided into clear steps, starting with obtaining the form from an employer and meticulously filling out the claimant's statement. It emphasizes punctuality in submission, advising claimants to file within 90 days to prevent delays in benefits processing. The inclusion of employer and doctor's statements as parts B and C respectively, ensures a collaborative approach to verifying claims, thereby streamlining the benefits disbursement process. The form also embodies a strong commitment to equality, barring discrimination based on a wide range of identities and conditions. In essence, the TDI-45 form stands as a testament to Hawaii's dedication to its workers, offering a structured yet compassionate framework for securing disability benefits. As such, it serves not just as a procedural necessity, but as a beacon of support for those in need.
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
Filling out the State of Hawaii TDI-45 form is a necessary step for claiming disability benefits. This procedure involves a collaborative effort between the claimant, their employer, and their doctor. Each party is responsible for completing their respective sections accurately to ensure a smooth claims process. Once submitted, the claim undergoes evaluation to determine eligibility for disability benefits. Timeliness and completeness in filling out the form can significantly impact the outcome and speed of the claim.
It is crucial to follow these steps carefully and provide accurate and complete information to avoid delays in the processing of your claim. Once all parts of the form are filled out and submitted, your employer or their insurance carrier will review your claim and notify you about your eligibility for benefits. Promptly addressing any requests for additional information will help expedite the review process.
What is the State Hawaii TDI-45 form used for?
The State Hawaii TDI-45 form is a document designed for employees in Hawaii to claim Temporary Disability Insurance (TDI) benefits. This form is crucial for those who are unable to perform their job duties due to a disability. It helps in initiating the process to receive financial support during the period of their disability.
How can I obtain the State Hawaii TDI-45 form?
The form can be obtained from your employer. It's important to reach out to your employer's human resources or administrative department to request this form. They are responsible for providing you with the necessary paperwork to file your claim.
What are the steps to file a claim using the TDI-45 form?
To successfully file a claim, the following steps should be taken:
Providing accurate and complete information while following these steps will help avoid any unnecessary delays in receiving your benefits.
What is the deadline for submitting the TDI-45 form?
You should present your TDI-45 form to your employer no later than 90 days after the start of your disability. If unforeseen circumstances prevent you from filing within this period, attach a statement to your form explaining why the claim was delayed. Timely submission is vital for the processing of your claim.
What happens after I submit my TDI-45 form?
After submission, your employer or their insurance carrier will review your claim and notify you about your eligibility for disability benefits. It is critical to ensure all parts of the form are filled out correctly to facilitate a smooth review process.
What if my disability was caused by my job?
If your disability was job-related, indicate this on the form by selecting "Yes" to the question regarding if the disability was caused by your job. This information is critical as it may affect the type of benefits you're eligible for, and further documentation or a different process involving Workers’ Compensation may be required.
Are there any other benefits I should report when applying for TDI?
Yes, you must report if you are receiving or claiming any additional benefits such as Federal Disability Insurance Benefits, Unemployment Insurance Benefits, Workers’ Compensation Benefits, or any other form of compensation. This is necessary to accurately assess your eligibility and the amount of TDI benefits you can receive.
What is the importance of ensuring my doctor completes Part C accurately?
The information your doctor provides in Part C (Doctor’s Statement) is crucial for determining the extent of your disability and your eligibility for benefits. Detailed and accurate information about your diagnosis, treatment, and expected recovery timeline are essential components in evaluating your claim.
How do discrimination and equal opportunity laws apply to the TDI-45 form process?
The Department of Labor and Industrial Relations policies ensure that no person shall be discriminated against or denied benefits based on race, color, sex, marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation, and National Guard participation. These principles ensure fairness and equal treatment throughout the claim process.
Not obtaining the claim form (TDi-45) from their employer in time or not at all, leading to confusion or delays in filing.
Failing to answer all questions in Part A - Claimant’s Statement thoroughly. Incomplete answers can cause unnecessary hold-ups in processing the claim.
Omitting the signature at the end of Part A or not having a responsible person sign if they are unable to do so themselves. This is a critical step for the validity of the claim.
Missing the 90-day filing deadline without attaching a statement explaining the reason for the delay. Timely filing is essential for a smooth claims process.
Overlooking the importance of having the employer complete and sign Part B - Employer's Statement. This part verifies employment and wage information which is vital for determining benefit eligibility.
Not ensuring that the doctor completes and signs Part C - Doctor’s Statement. Accurate and comprehensive medical information from a healthcare provider is critical for supporting the disability claim.
Incorrectly filling out employment and disability information, such as forgetting to specify if the disability was caused by the job or inaccurately reporting wages and hours worked. This information is crucial for assessing the claim.
Neglecting to check and properly answer questions regarding additional benefits being received or claimed, like Federal Disability Insurance or Workers' Compensation Benefits. This oversight can lead to discrepancies in the benefits awarded.
Ensuring that each step of filling out the form is approached with accuracy and care can significantly impact the outcome and efficiency of processing disability benefits claims. Individuals are encouraged to closely review their application for completeness and correctness before submission.
When filing a claim for disability benefits in Hawaii, particularly with the State Hawaii TDI-45 form, individuals find it necessary to accompany this form with several other documents to ensure a smooth and comprehensive claims process. These documents play a crucial role in providing a detailed account of the individual's employment background, medical condition, and eligibility for benefits. Understanding the purpose and requirement of each document can significantly aid in the preparation and submission of a complete disability benefits claim.
Together, these documents, when submitted alongside the State Hawaii TDI-45 form, enable a thorough evaluation of the disability claim. Collecting and accurately filling out these forms is a critical step toward securing the deserved benefits. Ensuring all necessary documentation is in order can significantly expedite the claims process, allowing for a smoother and more efficient resolution for the claimant.
The State Hawaii TDI 45 form shares similarities with other disability and insurance claim forms used across the United States, each serving a distinct purpose but structured to collect comparable types of information from claimants, employers, and medical professionals. Understanding these similarities can help individuals navigate the process of filing for benefits more smoothly.
The Federal Social Security Disability Insurance (SSDI) application form is one document that shares commonalities with the Hawaii TDI 45 form. Both forms require detailed personal information, employment history, and specifics about the disability affecting the claimant. Additionally, they request data on any other benefits the claimant might be receiving or eligible for. Where they diverge, however, is in their scope and purpose: the SSDI form is used to apply for disability benefits provided by the federal government on a long-term basis, whereas the Hawaii TDI 45 form pertains to temporary disability insurance claims at the state level, highlighting how forms can be tailored to different programs while retaining a core set of informational needs.
Workers' Compensation Claim forms found in various states also show similarities to the State Hawaii TDI 45 form. These forms typically include sections for the injured employee, the employer, and the attending physician—mirroring the structure of the TDI 45 form. They gather detailed information on the nature of the injury or illness, the circumstances under which it occurred, and the resulting limitations. The key difference lies in the specificity of workers' compensation forms to injuries or illnesses that are work-related, emphasizing the requirement for a causal link to the claimant’s employment, whereas the TDI 45 form can cover disabilities not caused by the job itself.
The Employer’s First Report of Injury or Illness form, which is another common document in the workers' compensation process, provides an interesting point of comparison as well. Like the TDI 45 form, this report necessitates details from the employer regarding the employee's work status and the circumstances of the reported injury or illness. Both types of documents serve as critical initial steps in the claim process, though this Workers' Compensation form specifically initiates a claim related to work-related injuries, unlike the broader applicability of the TDI 45 form in covering any temporary disability.
When filling out the State Hawaii TDI-45 form for disability benefits, it's crucial to follow specific guidelines to ensure the process goes smoothly. Here are the things you should and shouldn't do:
Understanding the State Hawaii Temporary Disability Insurance (TDI) Form TDI-45 can sometimes be challenging due to prevalent misconceptions. Here we clarify four common misunderstandings to provide clearer insight into the process and requirements.
Clear understanding and accurate completion of the TDI-45 form are essential for the timely and correct processing of disability benefit claims in Hawaii. Dispelling these misconceptions ensures that all parties involved have a cohesive understanding of the requirements and processes, facilitating a smoother claim experience.
Filing a claim for disability benefits in the State of Hawaii requires attention to detail and promptness. Here are key takeaways to ensure accuracy and efficiency in the process:
Following these guidelines diligently can help to ensure that the process of claiming disability benefits is as smooth and swift as possible, enabling the claimant to receive the necessary support during their period of disability.
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