Instructions to Complete Employer’s TDI Premium Statement 2022-2023
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.
Enter the number of male and female employees as of the 12th of each month for this reporting period.
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.