Sharing Our Life With Yours
Full / Legal Name of Business:
Applicant is: J Corporation J Association J Partnership J Proprietorship J Other
Name of Owner or President:
Nature of Business: Telephone:
City: State: Zip:
Name and Billing Address or CPA / PA (for billing purposes if different from above address):
Hawaii Unemployment Insurance Number (DOL Number):
Federal Identification Number:
Basic TDI Only:
Number of Employees
Male Female Total Premium rate quoted Employer
per $100 of covered payroll $.
Total taxable wages per month of covered employees:
(Maximum covered wages per employee per month: $3,803.32 for 2009)
Are all employees to be covered by this policy? J Yes J No
Percentage of premium paid by employer: ____________________________%
If applying for sole proprietor or partnership coverage, please list name(s). Each must be actively engaged in the business:
Optional TDI Riders (Not available to sole proprietors):
Employer Paid: J TDI Extension (TDI-Ext.) $0.10 per $100 covered payroll
J Group Life (GL) $0.10 per $100 covered payroll*
* GL rate is based on a plan of one (1) times the Employee’s maximum TDI Benefit, and is not available to all industries or age groups.
Certain restrictions and exclusions apply.
The insurance company reserves the right to establish new premium rates as provided in the policy.
Authorized Signature: ____________________________________________ Title: _______________________ Date: _______________________
Agency: _______________________________________________________ Agent: ______________________ Code: ______________________
Form No. TDI-107 1/09 Pacific Guardian Tower, 1440 Kapiolani Boulevard, Honolulu, Hawaii 96814