EPIC TDI-45 Part B

  • Aloha,

    We look forward to caring for your employee throughout their disability.

    For your convenience, we will complete the employer’s section of the TDI-45 form for you. Please provide the required employment information regarding your employee via this short questionnaire.

    If further information is needed, a Claim Specialist will contact you within the next business day.

    Mahalo,

    Your EPIC Claims Team

  • PART B - EMPLOYER'S STATEMENT

  • Format: (000) 000-0000.
  • Date of Hire:*
     - -
  • Date Employee Last Worked:*
     - -
  • If returned to work, give date:
     - -
  • Full Time or Part Time:

  • Employee's Wage Information

    If employee was paid on a salary basis, enter the weekly or monthly salary earned in the last week or month prior to the date their disability began:  
  • Rows

  • If the employee received any or all earnings on a commission or piecework basis, enter these earnings for the last 52 weeks prior to the date employee's disability began.
    This covers the period from    Pick a Date   through   Pick a Date   
    Earnings:          

  • Rows

  • Percentage of TDI premium paid by:

    Employer:      Employee:

  • Check the days normally worked:
  • Has or will this employee receive any of the following benefits for the period of disability covered by this claim?
  • Do you think this disability was caused by employee's job?

  • Signatures

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  • I hereby certify that the above information is true and complete to the best of my knowledge.

  • Clear
  • Date*
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  • Should be Empty: