• CLAIM FOR DISABILITY BENEFITS

    CLAIM FOR DISABILITY BENEFITS

  • INSTRUCTIONS FOR FILING PART C - PHYSICIAN'S STATEMENT FOR PATIENT DISABILITY BENEFITS

  • Answer all questions presented for Part C, Physician’s Statement.  It will automatically populate the Part C form once submitted electronically.

    Ensure that you sign your name electronically. By digitally signing, you are accepting the conditions to do business digitally with Pacific Guardian Life.

    If you choose not to submit the form electronically, you can download a PDF version of the for form by clicking here.

  • IMPORTANT

    To assist your patient in receiving Temporary Disability Insurance (TDI) benefits in a timely manner, it is crucial that you complete and submit this form as soon as possible to Pacific Guardian Life Insurance Company, Ltd.

    Please include the TDI Claim Application number if provided by the claimant when submitting this form.  You can leave the box blank if it's unknown.

  • Submitter's Email for Electronic Filing

    Pacific Guardian Life requires that you provide your email address to submit the claim electronically.  When you do the verify email step below, you will receive an email verification message with a code to confirm your email address. This may take a few seconds. 

  • Please complete and submit the PDF version of the TDI Claim Form. You can find the instructions, forms, and upload service here.

  • Pacific Guardian Life Insurance Logo
  • 1440 Kapiolani Blvd, Ste 1700 • Honolulu, HI 96814 • Phone: (808) 942-1282 • Fax: (808) 942-1284 • tdiclaims@pacificguardian.com

  • PART C - DOCTOR’S STATEMENT

    Temporary Disability Claim Form TDI-45 PART-C
  • Claimant Information

  • Disability Information

  • Pregnancy Details

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  • Employment Related Details

  • Hospitalization Details

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  • Treatment Details

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  • Referral Information

  • Attachments

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  • Electronic Record and Signature Disclosure and Consent to Electronic Transactions

  • Pursuant to applicable state and federal electronic transaction laws, you consent to sending and receiving electronic records and to the use of electronic signatures for certain documents. Your consent is strictly voluntary. Described below are the terms and conditions for sending and receiving electronic records; creating, viewing, and accessing account information on our online service center (also known as “portal”); and the use of electronic signatures. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by signing beneath the” Acceptance of Terms” below and providing information below.

    Applicable Documents

    This consent applies to information and documents; including but not limited to applications, application amendments, suitability or other forms, product illustrations, product disclosures, contracts, delivery receipts, and other communications made or exchanged under any policies or products offered or administered by Pacific Guardian Life Insurance Company, Limited (Pacific Guardian Life, we, us, or our). These electronic documents and communications will be sent to the email address you provide.

    Required Hardware and Software

    A web browser and document reading software is required to access and sign your documents. You may wish to view the full list of requirements on the vendor’s website. If these requirements change, you may be asked to re-accept the Consent to Electronic Transactions. At that time, you will have the right to withdraw your consent.

    Requesting Paper Copies

    You may request a paper version of any of the electronically furnished documents at any time by contacting Pacific Guardian Life’s TDI Claims Department at tdiclaims@pacificguardian.com or 808-942-1282. Paper copies will be provided without a fee.

    Update Your New E-mail Address – Notify Pacific Guardian Life

    To inform us of a change in your e-mail address for use in sending or receiving electronic documents, contact Pacific Guardian at tdiclaims@pacificguardian.com or 808-942-1282. In the body of such request, state your name, your previous e-mail address, and your new e-mail address.

    Withdrawing Your Consent

    You may withdraw this consent at any time by sending an email to tdiclaims@pacificguardian.com and notifying us that you no longer consent to sending and receiving electronic records, the use of electronic signatures, or viewing and accessing information on the online portal. You will need to provide us with your name, email address, and contract number.

    Additional Online Services

    As we strive to provide more capabilities and services, we may add additional online services in the future.  Therefore, as a condition of accessing or retrieving those additional services, you may be asked to agree to different or additional terms and conditions should our services change. 

  • Pacific Guardian Tower

    1440 Kapiolani Boulevard, Suite 1700, Honolulu, HI 96814

    (808) 955-2236 | www.pacificguardian.com

  • Contact Information and Signature

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