Answer all questions presented for Part A, Claimant’s Statement. It will automatically populate the Part A form once it is submitted electronically.

Make sure to sign your name electronically, or if you are unable to, have a responsible person sign for you.  By digitally signing, you are accepting conditions to do business digitally with Pacific Guardian Life.

Upon your submission of Part A, please pay attention to information provided to you on the Thank you page as there is information you will need to open the completed/signed claim document as well as instructions on what you can expect as next steps. 

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

IMPORTANT

We must receive the completed and signed forms for Part A (Claimant), Part B (Employer), and Part C (Doctor) to process your claim. 

Please contact your employer and doctor with your request to complete Part B (Employer) and Part C (Doctor).  We provide the links to Part B and Part C in the confirmation email once Part A is completed and submitted.  A TDI Claim Application # is also provided at time of submission.  Please provide this Application # to your employer and doctor (TDI-Claim-XXXXX) to expedite the process.

To avoid unnecessary delays, present your claim form 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, we will notify you if you are eligible for benefits.

Disclaimer:  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.

Submitter's Email

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.

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

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.