Temporary Disability Insurance (TDI) Claim Form

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The Temporary Disability Insurance (TDI) Claim Form will need a Claimant’s Statement, Employer’s Statement, and Doctor’s Statement to be completed.

Instructions for Filing a Claim for Disability Benefits:

  1. Obtain a claim form (TDI-45) from your employer.
  2. Answer all questions in Part A, Claimant’s Statement. Please type or print. Make sure to sign your name, or if you are unable to, have a responsible person sign for you. To avoid unnecessary delays, present your claim form to your employer 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, your employer or employer’s insurance carrier will notify you if you are eligible for benefits.
  3. Have your employer complete and sign Part B, Employer’s Statement.
  4. Have your doctor complete and sign Part C, Doctor’s Statement. Have your doctor mail this form to the insurance carrier listed, unless otherwise directed by your employer in Part A (23) or Part B (13).


Using a blue or black ink pen

Submit in 1 of 3 Ways

Email: [email protected]

Fax: (808) 942-1284

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