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Free State Hawaii Tdi 45 Template

The State Hawaii TDI 45 form is a document used to claim temporary disability benefits in Hawaii. It requires the claimant to provide personal information, details about the disability, and employment history. Proper completion and timely submission of this form are essential for receiving benefits without unnecessary delays.

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Overview

The State of Hawaii's TDI 45 form plays a crucial role in the process of applying for Temporary Disability Insurance (TDI) benefits. This form is specifically designed for individuals who are unable to work due to a disability, whether caused by an illness or an accident. To initiate a claim, claimants must first obtain the TDI 45 form from their employer and fill out Part A, which includes personal information and details about the disability. Timeliness is essential; claims should be submitted within 90 days of the onset of the disability to avoid delays. Employers are required to complete Part B, providing necessary information about the claimant's employment status and wages. Additionally, a doctor must fill out Part C to verify the medical aspects of the claim. Each section of the form is structured to gather specific information, ensuring that the claim is processed efficiently. Importantly, the TDI program is designed to be accessible and equitable, prohibiting discrimination based on various personal characteristics. Understanding the steps involved in completing the TDI 45 form is vital for anyone seeking disability benefits in Hawaii.

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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

Hours

Wages

Employer name and address

Month

Day

Year

Month

Day

Year

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

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

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:

Calendar

No. of

No. of Hours

Total Wages

Quarter Ending

Weeks Worked

Worked Per Wk.

Earned

11.

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

o Yes

o No

o Unknown

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

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)

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).

Claimant’s Name

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?

o Yes

o No

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

If yes, filed with _____________________________________________________________

Was claimant hospitalized?

o Yes

o No

If yes, from ______________________ to ______________________

Surgery indicated?

o Yes

o No

Type _____________________________________________________________

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 ____________________________________________________

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.

How to Fill Out State Hawaii Tdi 45

Filling out the State Hawaii TDI 45 form involves several important steps. This form is necessary for claiming disability benefits. It requires information from the claimant, employer, and doctor. Be sure to complete each part accurately to ensure a smooth process.

Obtain the TDI-45 claim form from your employer.
Fill out Part A, the Claimant’s Statement. Include your name, Social Security number, birth date, mailing address, and telephone number. Choose your gender and marital status. Describe the cause of your disability and provide the date you first became unable to work. Indicate whether the disability was job-related. State if you have recovered or returned to work, and provide relevant dates.
Have your employer complete and sign Part B, the Employer’s Statement. They need to provide details about your employment and wage information.
Ask your doctor to complete and sign Part C, the Doctor’s Statement. Ensure that your doctor mails this part to the insurance carrier listed unless instructed otherwise by your employer.
Submit the completed form to your employer within 90 days of becoming unable to work. If you miss this deadline, include a statement explaining the delay.

Once the form is submitted, your employer or their insurance carrier will review your claim and notify you of your eligibility for benefits. Make sure to keep copies of all documents for your records.

Common mistakes

Filling out the State Hawaii TDI 45 form can be a straightforward process, but many people make common mistakes that can delay their claims. One of the most frequent errors is failing to complete all sections of Part A, the Claimant’s Statement. Each question must be answered thoroughly. Leaving even one question blank can lead to unnecessary delays in processing your claim.

Another mistake is not signing the form. Claimants often forget to sign their name, or they may ask someone else to sign without ensuring that person is authorized. If you cannot sign, make sure a responsible person signs on your behalf and includes their relationship to you. This oversight can cause your claim to be rejected.

Many individuals also miss the 90-day filing deadline. It’s crucial to submit your claim within this timeframe. If you file late, you must include a statement explaining why. Not doing so can result in your claim being denied. Keep track of your dates and submit your claim as soon as possible.

People sometimes fail to provide detailed information about their disability. In question 8, it’s important to describe how the disability occurred, including the date, place, and circumstances if it was an accident. Vague responses can lead to confusion and may require additional follow-up from the insurance carrier.

Another common issue arises in Part B, the Employer’s Statement. Employers must complete and sign this section promptly. Delays from the employer’s side can slow down the entire process. Employers should ensure that they provide accurate wage information and that all required fields are filled out.

Claimants often overlook the requirement to report other benefits they are receiving. In question 20, it’s essential to disclose any additional benefits, such as unemployment or workers’ compensation. Failing to do this can raise red flags and complicate the claim process.

Lastly, many people forget to check the mailing instructions for the doctor’s statement in Part C. The form requires that this statement be mailed to the correct insurance carrier. If the doctor sends it to the wrong address, it could delay your claim significantly. Always double-check that the form is sent to the right place.

Documents used along the form

The State of Hawaii TDI-45 form is a crucial document for individuals seeking temporary disability benefits. However, several other forms and documents often accompany this claim to ensure a comprehensive evaluation of eligibility and benefits. Below is a list of these related documents, each serving a specific purpose in the claims process.

Employer's Report of Industrial Injury (WC-1): This form is used by employers to report workplace injuries. It provides essential details about the incident, including the nature of the injury and the circumstances surrounding it. This report is vital for determining if the injury is work-related.
Physician's Report (WC-2): This document is completed by the claimant's doctor and provides a detailed account of the medical condition leading to the disability. It includes diagnosis, treatment history, and the expected duration of the disability, which helps assess the claim's validity.
Claimant's Authorization for Release of Information: This form allows the insurance carrier to obtain necessary medical records and information from healthcare providers. It ensures that the insurance company has access to relevant information to process the claim efficiently.
Social Security Administration Disability Benefits Application: If applicable, this form is used to apply for federal disability benefits. Claimants may need to provide this information to demonstrate their overall disability status and any additional benefits they may be entitled to.
Unemployment Insurance Benefits Application: This document is necessary for individuals who are also seeking unemployment benefits. It helps to clarify the claimant's financial situation and any other benefits being received during the disability period.
Mobile Home Bill of Sale Form: To ensure a smooth transaction process, refer to our comprehensive Mobile Home Bill of Sale documentation for all necessary details and legal compliance.
Employer's Sick Leave Plan Documentation: If the claimant is receiving sick leave benefits from their employer, this documentation outlines the terms and conditions of those benefits. It provides a clearer picture of the claimant's financial support during their disability.
Union Benefits Claim Form: For union members, this form may be required to claim any additional benefits provided by their union during periods of disability. It ensures that all potential sources of support are considered in the claims process.

Understanding these accompanying forms and documents is essential for individuals navigating the disability benefits process in Hawaii. Each document plays a vital role in ensuring that claims are processed accurately and efficiently, ultimately supporting claimants during their time of need.

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Obtain Answers on State Hawaii Tdi 45

What is the TDI-45 form?

The TDI-45 form, also known as the Claim for Disability Benefits, is a document used in Hawaii for individuals seeking temporary disability insurance benefits. This form allows claimants to report their disability status and provides necessary information for their employer and healthcare provider to complete their claims.

How do I fill out the TDI-45 form?

Filling out the TDI-45 form involves several steps:

Obtain the form from your employer.
Complete Part A, known as the Claimant’s Statement. Ensure all questions are answered and sign the form.
Your employer must fill out Part B, the Employer’s Statement.
Your doctor needs to complete Part C, the Doctor’s Statement, and send it to the insurance carrier.

Make sure to submit the form within 90 days of your disability to avoid delays.

What information do I need to provide in Part A?

In Part A, you will need to provide personal details, including:

Your full name and Social Security number.
Your birth date and mailing address.
Details about your disability, such as the cause and the date you were unable to work.
Employment information, including your employer's name and your job title.

Accurate and complete information helps expedite the claims process.

What if I miss the 90-day filing deadline?

If you are unable to file your claim within the 90-day timeframe, you must attach a statement explaining the reason for the delay. This is crucial for ensuring that your claim is still considered for benefits.

Can I receive other benefits while claiming TDI?

Yes, you can receive other benefits while claiming TDI. The TDI-45 form allows you to indicate if you are receiving or claiming additional benefits such as federal disability insurance, unemployment insurance, or workers’ compensation. Be sure to check all applicable boxes on the form.

Who is responsible for submitting the Doctor’s Statement?

The claimant's doctor is responsible for completing and submitting the Doctor’s Statement (Part C) to the insurance carrier. This step is essential as it provides medical verification of your disability.

What happens after I submit the TDI-45 form?

After submitting the TDI-45 form, your employer or their insurance carrier will review your claim and notify you of your eligibility for benefits. This process typically occurs within ten days, so keep an eye on your mail or email for updates.

Document Attributes

Fact Name	Description
Form Title	The form is officially titled "Claim for Disability Benefits" and is designated as TDI-45.
Governing Law	This form is governed by Hawaii's Temporary Disability Insurance (TDI) law, specifically HRS Chapter 392.
Filing Deadline	Claims must be submitted within 90 days of the inability to perform job duties to avoid delays.
Claimant's Statement	Part A requires the claimant to provide personal information, including their name, social security number, and details about their disability.
Employer's Statement	Part B must be completed by the employer, providing necessary employment details to support the claim.
Doctor's Statement	Part C requires the claimant's doctor to complete and certify the medical information related to the disability.
Non-Discrimination Policy	The form includes a statement ensuring that no person shall face discrimination in accessing TDI benefits.
Additional Benefits	Claimants must disclose any other benefits they are receiving, such as unemployment or workers’ compensation.
Signature Requirement	The claimant must sign the form, or a representative may sign if the claimant is unable to do so.
Submission Instructions	The completed form should be submitted to the insurance carrier indicated on the form, following the specified steps.

Misconceptions

Misconception 1: The TDI 45 form is only for employees who have been injured at work.

This is not accurate. The TDI 45 form can be used for any disability, whether caused by an accident or illness, regardless of its relation to the workplace. Claimants must simply provide the appropriate details about their condition.

Misconception 2: You must submit the TDI 45 form immediately after becoming disabled.

While timely submission is important, claimants have up to 90 days to file the form. If filing occurs after this period, it is necessary to include a statement explaining the delay. This allows for some flexibility in the process.

Misconception 3: Only full-time employees are eligible for TDI benefits.

This is incorrect. Both full-time and part-time employees can qualify for TDI benefits as long as they meet the necessary criteria and have contributed to the program. Employment status does not exclude part-time workers from receiving assistance.

Misconception 4: Employers have no responsibility in the TDI claim process.

Employers play a crucial role in the TDI claim process. They are required to complete and sign the Employer's Statement section of the TDI 45 form. Their timely cooperation can significantly affect the speed at which benefits are processed.

Key takeaways

When filling out and using the State Hawaii TDI 45 form, keep these key takeaways in mind:

Timeliness is Crucial: Submit your claim within 90 days of being unable to perform your job duties. If you miss this window, include a statement explaining the delay.
Complete All Sections: Ensure that all parts of the form—Claimant’s Statement, Employer’s Statement, and Doctor’s Statement—are filled out completely and accurately to avoid delays in processing.
Signatures Matter: Your signature is essential. If you cannot sign, have someone responsible sign on your behalf. This applies to both the claimant and the employer.
Doctor's Role: Your doctor must complete and send their section of the form to the insurance carrier within seven working days. This step is vital for the timely processing of your claim.
Disability Information is Key: Clearly describe the nature of your disability, including whether it was caused by an accident or illness, and provide specific details about the incident.
Keep Copies: Always retain copies of the completed form and any supporting documents for your records. This can be helpful if any questions arise during the claims process.