EPIC TDI-45 Part A

  • Aloha,

    We look forward to assisting you with your claim throughout your disability. For your convenience, we can complete your section of the TDI-45 form for you. Please answer this short questionnaire to the best of your ability.

    Mahalo,

    Your EPIC Claims Team

  • PART A - CLAIMANT INFORMATION

  • Date of Birth:*
     / /
  • Gender:
  • Marital Status:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Disability Information

  • Disability was caused by:*
  • 0/150
  • What was the first day you were unable to perform the duties of your job?*
     - -
  • Was the disability caused by your job?*
  • Did you want to receive email updates about your claim?
  • Did you want to receive text message updates about your claim?
  • Have you recovered from your disability?
  • If Yes, date recovered:
     - -
  • Have you returned to work?*
  • If Yes, date returned to work:
     - -

  • Employer Information

  • Employment from:
     - -
  • Employment to:
     - -
  • Full Time or Part Time:
  • Pay type:
  • Are you a union member?
  • Did you work for any other Hawai`i employers during the past 52 weeks?
  • Does your employer have a printed TDI notice posted and maintained conspicuously in your employment area?
  • Did your employer inform you of your entitlement to TDI benefits?

  • Other Benefits

  • In addition to TDI benefits, are you receiving or claiming benefits from the following (check all that apply):
  • During the 52 weeks (one year) prior to this disability, did you receive TDI benefits for other periods of disability?
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  • I hereby claim Temporary Disability Benefits and certify that the foregoing statements, including any accompanying statements, are true and complete to the best of my knowledge.

  • Clear
  • Clear
  • Date
     - -
  •  
  • Should be Empty: