Form Hrd(Tdi)-1 - Claim For Temporary Disability Benefits Page 2
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3PART A – CLAIMANT’S STATEMENT (CONTINUED)
OTHER BENEFITS
18. In addition to TDI benefits, I am receiving or claiming benefits from the following:
Fed. Disability Ins. Benefits
Unemployment Ins. Benefits
Damages for Personal Injury
Workers’ Comp. Benefits
State Sick Leave Plan
Accidental Inj. Lv. (Act 64)
Other (Health & Welfare Fund, Union Plan, etc.)
19. During the current calendar year, I have received TDI benefits for other periods of disability.
Yes,
No
If yes, from whom
From
to
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.
Claimant’s signature:
Date:
Representative’s signature, if claimant unable to sign
Print Representative’s Name & Relationship
PART B – DOCTOR’S STATEMENT
IMPORTANT: Please complete and mail within 7 working days after examination to the employee’s department (see top portion of
first page for department’s mailing address).
1.
Claimant’s Name:
2.
Physical requirements of claimant’s occupation as related by claimant:
3.
Diagnosis:
4.
If pregnancy advise EDC
. If disability is pregnancy with complications, advise in item #3 above.
5.
Was claimant’s disability caused by his/her employment:
Yes
No
If yes, was Physician’s Report WC-2 filed?
Yes
No
If yes, filed with
6.
Was claimant hospitalized?
Yes
No
If yes, from
to
Surgery indicated?
Yes
No
Type:
7.
Complete the following:
Mo.
Day
Yr.
a. Date of your first treatment of this disability
b. First date claimant unable to perform the duties of employment (see 2 above)
c. Date of your most recent treatment of this disability
d. Estimated date claimant will be able to perform usual work (see 2 above)
8.
Are you referring claimant to another physician
or was claimant referred to you
?
Give name of physician:
I hereby certify that the above information is true and complete to the best of my knowledge.
Print Dr.’s name:
Office Add.:
Doctor’s signature:
Tel. No.
Date:
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