TDI CLAIM FORM

CLAIM FOR DISABILITY BENEFITS
INSTRUCTIONS FOR FILING PART B - EMPLOYER STATEMENT FOR CLAIMS FOR DISABILITY BENEFIT
Answer all questions presented for Part B, Employer’s Statement. It will automatically populate the Part B form once submitted electronically.

Make sure to sign your name electronically. By digitally signing, you are accepting 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 form by clicking here.

IMPORTANT

To assist your employee in receiving Temporary Disability Insurance (TDI) benefits in a timely manner, it is important that you complete and submit this from 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.
Please enter TDI Claim Application number provided by claimant:
TDI Claim ID - Display
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.
Email Verification*
Employer's Verified Email Address*
If you do not have an email address, click below.

I do not have an email address.
Please complete and submit the PDF version of the TDI Claim Form. You can find the instructions, forms, and upload service here.
Acknowledgement for Instructions to File TDI Claim Online*

PART B - EMPLOYER’S STATEMENT
Employer Information
Firm or Trade (Business) Name*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Group Number
Account Number
Employer Dept. of Labor No.*
% Premium Paid by Employer*

52 Week Work History

Enter the following for the last 52 weeks prior to the date the employee's disability began:*

	Calendar Quarter Ending	No. of Weeks Worked	No. of Hours Worked Per Wk.	Total Wages Earned
1
2
3
4
5

Disability Information
Date last worked prior to disability:*

MonthDayYear
Date
If returned to work, give date

MonthDayYear
Date
Do you think this disability was caused by claimant's job?

YesNoUnknown
Was an Employer's Report of Industrial WC-1 filed?

YesNo
If yes, advise name and address of Worker's Compensation carrier:

Attachments
If you have additional documents or files you may upload up to 3 attachments.

Limit to 9mb total file size. Accepted formats: (pdf, doc, docx, xls, xlsx, csv, txt, rtf, zip, jpg, jpeg, png, gif, webp, avif)
Cancelof
Please describe the attachment contents and relevance to this claim.
do not include any personal information

Doctor Statement Information
Mail doctor's statement to:
Other Information
Please share any other relevant information for this claim
Other Information Header

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.
Consent Acknowledgement*

I consent and agree to receive and send mailings and communications electronically, the use of electronic signatures, access to the online portal, and the Consent to Electronic Transactions set forth above. I further consent and agree that if I use an electronic signature, it is enforceable under applicable state and federal law and is equivalent to a manual signature. I also acknowledge that the email address provided is the email address of the person who has consented to this electronic disclosure.
Pacific Guardian Tower

1440 Kapiolani Boulevard, Suite 1700, Honolulu, HI 96814

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

Certification/Signature
Name of employer or employer’s representative*
Title*
Employer Tel No.*
Employer Fax No.
I hereby certify that the above information is true and complete to the best of my knowledge.*

Powered by Jotform SignClear
Signature of employer or employer’s representative
Date*

MonthDayYear
Date
Please verify that you are human*
override_email_name
Should be Empty:

	Week Ending Date	No. Days Worked	Gross Amount $
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8

	Yes	No
Wages
Salary
Sick Leave Pay
Vacation Pay
Separation Pay

CLAIM FOR DISABILITY BENEFITS

INSTRUCTIONS FOR FILING PART B - EMPLOYER STATEMENT FOR CLAIMS FOR DISABILITY BENEFIT

PART B - EMPLOYER’S STATEMENT

Employer Information

Claimant Information

Employment Information

Wage Information

52 Week Work History

Disability Information

Wages/Salary received during period of disability

Attachments

Doctor Statement Information

Other Information

Electronic Record and Signature Disclosure and Consent to Electronic Transactions

Certification/Signature