Form Hrd(Tdi)-1 - Claim For Temporary Disability Benefits
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1
2
3Department’s Mailing Address:
HRD(TDI)-1
Department:
Rev. 2/00
Attn:
Address:
CLAIM FOR TEMPORARY DISABILITY BENEFITS
INSTRUCTIONS: To avoid unnecessary delay, present your claim form to your department under Step 3, below, 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, a departmental representative will notify you if you are eligible for benefits. Follow the 3 steps below:
Step 1. Answer all questions in Part A, Claimant’s Statement. Make sure you sign your name, or if you are unable to, have a
responsible person sign for you.
Step 2. Have your doctor complete and sign Part B, Doctor’s Statement.
Step 3. Have your doctor mail this form to your department (see top portion of this page for your department’s mailing address).
PART A – CLAIMANT’S STATEMENT
1.
My name is:
(First, middle, last)
Type or print
2.
Social Security Number
3.
Address
(Street, City or Town, State, Zip Code)
4.
Telephone Number
DISABILITY INFORMATION
5.
My disability was caused by:
sickness,
accident. Describe (if accident, give date, place and circumstances):
6.
The first day I was unable to perform the duties of my job:
7.
Was this disability caused by your job?
Yes,
No,
Unknown
(month)
(day)
(year)
8.
I
have not
have recovered from my disability.
9.
I
have not
have returned to work.
Date recovered:
Date returned to work:
EMPLOYMENT INFORMATION
10. Department:
11. Work Address:
Division:
(Street)
(City)
(State) (Zip)
12. Prior to my disability, I worked for this employer
13. I worked:
14. I earned:
From
to
Hrs. per week
$
per week
(Mo.)
(Day)
(Yr.)
(Mo.)
(Day)
(Yr.)
15. Occupation:
16. Bargaining Unit:
BU
or
Excluded
17. Other Hawaii employers I worked for during the past 52 weeks.
Period of Employment
Weekly
From
To
Hours
Wages
Employer Name and Address
Mo.
Day
Yr.
Mo.
Day
Yr.
a.
b.
c.
d.
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