The Pacific Guardian Life TDI-45 form is Hawaii’s temporary disability insurance claim form, and it has three parts: you complete Part A, your employer completes Part B, and your treating medical provider completes Part C. Once all three parts are done, the form goes to Pacific Guardian Life’s Honolulu office by fax or mail. You have 90 days from the day you become unable to work to get your claim to your employer, so the sooner you start, the better.
Getting a Copy of the Form
The TDI-45 is not available for download from Hawaii’s Department of Labor website.1State of Hawaiʻi Department of Labor and Industrial Relations. Forms – Disability Compensation Division If your employer carries TDI coverage through Pacific Guardian Life, you have two ways to get one. You can complete the form through Pacific Guardian Life’s online portal, or you can ask your employer for a paper copy.2Pacific Guardian Life. Temporary Disability Insurance (TDI) Claim Form If your employer does not keep blank forms on hand, call Pacific Guardian Life directly at (800) 367-5354 toll-free, or (808) 955-2236 from Oahu.
If you are filling out a paper copy, use blue or black ink.2Pacific Guardian Life. Temporary Disability Insurance (TDI) Claim Form
Part A: Your Statement
Part A covers Blocks 1 through 22 and is yours to complete. You will provide personal identifying information, contact details, a description of your medical condition, the date your disability began, and the last day you worked.3Pacific Guardian Life. Instructions to Complete TDI Claim Form Sign and date the form at the end of this section. If you are physically unable to sign, a responsible person can sign on your behalf.
Hand the form to your employer once Part A is finished so they can fill in Part B.
Part B: Your Employer’s Statement
Your employer completes Part B. This section documents your work and earnings history, typically including your hire date, your average weekly wage, and confirmation that you were covered under the employer’s TDI policy when your disability began.3Pacific Guardian Life. Instructions to Complete TDI Claim Form The average weekly wage reported here drives your benefit amount, so it is worth asking your employer to double-check the figure. The employer signs this section before passing the form along.
Part C: Your Doctor’s Statement
Part C is completed by your treating physician, surgeon, chiropractor, naturopath, physician assistant, or advanced practice registered nurse. The provider certifies your disability, provides a diagnosis, notes the dates of treatment, and estimates when you can return to work.
Hawaii law gives the certifying provider seven working days from the date of examination to submit the completed proof of disability to you. A provider who misses that deadline without good cause can be fined $25 per late certification.4Justia. Hawaii Code 392-26 – Care by Physician, Advanced Practice Registered Nurse, or Equivalent Required Your doctor mails Part C directly to Pacific Guardian Life unless your employer has directed otherwise on the form.
Incomplete physician statements are the most common reason for delays in processing. Make sure your provider answers every question on Part C and includes an estimated return-to-work date.5State of Hawaiʻi Department of Labor and Industrial Relations. Frequently Asked Questions About Temporary Disability Insurance
Where to Submit the Completed Form
Once all three parts are complete, send the form to Pacific Guardian Life:2Pacific Guardian Life. Temporary Disability Insurance (TDI) Claim Form
- Fax: (808) 942-1284
- Mail: Pacific Guardian Life, 1440 Kapiolani Blvd., Suite 1700, Honolulu, HI 96814
Present the claim to your employer no later than 90 days after you become unable to work. If you file beyond that window, attach a written statement explaining the delay; late claims risk reduced or denied benefits.2Pacific Guardian Life. Temporary Disability Insurance (TDI) Claim Form If you faxed the form, follow up with Pacific Guardian Life to confirm it was received. A missing page or an incomplete section from any of the three parties will slow things down.
Make Sure You Actually Qualify Before You File
Two eligibility rules trip up claims regularly. First, your work history: under Hawaii law, you qualify only if you worked at least 14 weeks during the 52 weeks before your disability started, and in each of those 14 weeks you were paid for 20 or more hours and earned at least $400. The 14 weeks do not have to be consecutive, and they can be spread across more than one employer.6Justia. Hawaii Code 392-25 – Eligibility for Benefits
Second, the disability must be unrelated to your job. On-the-job injuries and work-caused conditions fall under workers’ compensation, not TDI. TDI covers off-the-job injuries, illnesses, pregnancy, recovery from childbirth, and organ donation, and your condition must be serious enough that you cannot perform your regular job at all.7Justia. Hawaii Code 392-21 – Establishment of Temporary Disability Benefits
Some workers are excluded from mandatory TDI coverage altogether, including federal employees, insurance agents and real estate salespeople paid entirely on commission, minors under 18 who deliver newspapers, certain domestic workers, student nurses, interns, and some family employees.5State of Hawaiʻi Department of Labor and Industrial Relations. Frequently Asked Questions About Temporary Disability Insurance
After You File
Pacific Guardian Life reviews the submitted form and notifies you by mail whether your claim is approved or denied. Hawaii’s TDI law does not set a specific number of days for the carrier to decide, so timing depends on how complete the paperwork is.5State of Hawaiʻi Department of Labor and Industrial Relations. Frequently Asked Questions About Temporary Disability Insurance
Benefits do not start on day one. There is a seven-consecutive-day waiting period after your disability begins, and no benefits are paid for those days. Your first payable day is the eighth day.8State of Hawaiʻi Department of Labor and Industrial Relations. About Temporary Disability Insurance If approved, payments go retroactively to that eighth day and continue weekly for as long as your doctor certifies you remain unable to work, up to a maximum of 26 weeks in a single benefit year.
If Your Claim Is Denied
A denial comes in writing on Form TDI-46, and you receive three copies.8State of Hawaiʻi Department of Labor and Industrial Relations. About Temporary Disability Insurance Common denial reasons are failing the 14-week and $400 earnings test, missing medical certification that you are completely unable to work, or having a condition that should be filed under workers’ compensation.
You have 20 calendar days from the date the denial notice was mailed to appeal. Write your explanation on the notice itself and mail two copies to the Disability Compensation Division in Honolulu or to the nearest Department of Labor and Industrial Relations district office.8State of Hawaiʻi Department of Labor and Industrial Relations. About Temporary Disability Insurance That 20-day window is short. The Division will schedule a hearing to review your case.