Notice Of Data Event

Instructions to Complete TDI Claim Form

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Employer Resources
Individuals & Families Resources


Employers should complete this form with help from their employee and their employee’s physician.

Claims Administration

There are 3 parts to complete on the TDI Claim Form:

  • Part A: Claimant’s Statement Employee complete Blocks #1 through #22; signs and dates form.
  • Part B – Employer’s Statement – Employer completes this section.
  • Part C – Doctor’s Statement – Employee’s Physician completes this form.
    *The last person to complete form sends it to Pacific Guardian Life.

Upon receipt of TDI Claim Form

Claims administrator reviews for (If we are the TDI carrier/account is paid up to date):

  1. Part A – Claimant has completed all required information, form is signed.
  2. Part B – Employer’s portion is completed with all necessary information, form is signed.
  3. Part C – Physician’s Statement is completed with all necessary information, form is signed.
  4. Upon review of all information and claimant is eligible, benefit amount is calculated and sent for approval.
  5. If a claim is received with all documentation and approved, benefits may be processed within 3 to 5 working days.
  6. Claims that require additional information:
    a)The claim administrator will obtain additional information via the telephone and/or memo.
    b)On continuing claims, a supplementary claimant’s report will be requested upon the claim
    administrator’s requests to update his or her claim.

    Monthly FICA Statement is mailed to employer the first week of the following month. At year end, a summary of all claims paid during the year is mailed to employers the last week of December.


Using a blue or black ink pen

Submit in 1 of 3 Ways

Email: [email protected]

Fax: 1 (808) 942-1284

or Mail:
Pacific Guardian Life
1440 Kapiolani Blvd.,
Suite 1700
Honolulu, HI 96814