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
Employee's Name:*

1. First NameMiddle NameLast Name
Employee's Occupation/Job Title:
Name of Account/Policyholder:*
Employer Email:*
example@example.com
Employer Contact Phone:*
Please enter a valid phone number.
Employer's Address:

Street Address Line 2

CityState

Zip Code
Date of Hire:*

MonthDayYear
Date
Date Employee Last Worked:*

MonthDayYear
Date
If returned to work, give date:

MonthDayYear
Date
Full Time or Part Time:

Full TimePart time

Signatures
If you have any documentation to support this claim, please upload it here.

Cancelof
I hereby certify that the above information is true and complete to the best of my knowledge.
Signature of Employer or Employer's Representative

Clear
Title
Date*

MonthDayYear
Date
Should be Empty: