Instructions for Filing Employer’s TDI Premium Statement for 2022-2023
Reporting Period
The reporting period is from 1/1/2022-1/1/2023. All information to be provided on the Employer’s Premium Statement pertains to this reporting period.
Section A
Enter the number of male and female employees as of the 12th of each month for this reporting period.
Section B
- Total Wages
Enter the total gross wages of all employees to be covered under your Temporary Disability Plan.
PLEASE DO NOT INCLUDE THE WAGES FOR OWNERS WITH AT LEAST 50% OWNERSHIP OF THE COMPANY. - Total Amount of Covered Wages
Enter the total gross ‘covered’ wages of all covered employees up to, but not exceeding the maximum taxable wage per person which are:
Weekly
$1,200.30
Monthly
$5,201.30
Quarterly
$15,603.90
Annually
$62,415.60
PLEASE DO NOT INCLUDE THE WAGES FOR OWNERS WITH AT LEAST 50% OWNERSHIP OF THE COMPANY.
Example: If employee A’s annual gross wage is $63,000.00, his/her covered wage is $62,415.60 as that is the maximum allowable annual limit. If employee B’s annual gross wage is $50,000.00, his/her maximum covered wage is $50,000.00 as that is below the maximum annual limit. The total covered wages for both employees to be entered in Line 2 is $112,415.60 ($62,415.60+$50,000.00). - 2022 Premium
Enter your 2022 premium here. The premium for 2022 is calculated by multiplying the covered wage by the rate. If the amount is less than the minimum annual premium of $120.00, then the premium due will be $120.00 per year or $10.00 per month. - 2022 Estimated Premium Already Paid
This amount listed here is what you paid early this year. - Available Credit
The amount listed here is the available credit on your account, if any. - Subtotal
Subtract lines 4 and 5 from line 3. This amount is the credit or balance due for 2022. - 2023 Estimated Premium
This amount is based upon the prior year and should be the same as line 3. However,
– If your policy became effective after January 2022, then the amount due is calculated by
estimating your annual payroll from January 1 through December 31, 2022, multiplied by
the rate (for rate, see line 2 of your premium statement), but cannot be not less than the
minimum annual premium of $120.00 or $10.00 per month.
– If you are reporting for the complete year of 2022 and line 7 is less than line 3, please
provide a brief explanation as to why (e.g., business closing, downsizing, etc.) in the box
below. - Total Premium Due
Add lines 6 and 7 for the total amount due for 2022 premium and 2023 estimated premium.
Keep a copy of this completed premium statement for your records. Please make a check for the Total Premium Due (see line 8) payable to Pacific Guardian Life and include your group and account numbers along with the name of the account in the memo portion of your check. Send check along with your completed statement to:
PACIFIC GUARDIAN LIFE BOX 47839
P.O. BOX 1300
HONOLULU, HI 96807-1300
TO KEEP YOUR POLICY ACTIVE, all information on this premium statement must be completed and payment must be received by Pacific Guardian Life.
