Temporary Disability Insurance Application

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                                           Sharing Our Life With Yours
                                                                                                                          Temporary Disability
                                                                                                                         Insurance Application

Full / Legal Name of Business:

dba:


Applicant is:       J Corporation       J Association           J Partnership        J Proprietorship        J Other

Name of Owner or President:

Nature of Business:                                                                                        Telephone:

Address:

City:                                                  State:                                                   Zip:

Name and Billing Address or CPA / PA (for billing purposes if different from above address):




                                                                                                          Telephone:

Hawaii Unemployment Insurance Number (DOL Number):


Federal Identification Number:

Effective Date:


    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
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