TDI Self-Insurers Plan Certification And Agreement {TDI-15}

FORM TDI-15 - TDI SELF-INSURER’S PLAN CERTIFICATION AND AGREEMENT. This form s used by Hawaii employers who wish to operate their own Temporary Disability Insurance (TDI) plan instead of purchasing coverage through a traditional insurance carrier. Under Hawaii law, employers are required to provide TDI benefits to eligible employees who are unable to work due to non-work-related illness, injury, pregnancy, or organ donation. This form serves as both a certification of the employer’s self-insured plan and an agreement to comply with all requirements of the Hawaii TDI statutes and administrative rules. Employers must outline their plan’s benefit provisions, including the percentage of wages replaced, the waiting period before benefits begin, and the maximum number of weeks covered, ensuring the benefits are at least as favorable as those required by law. The form also requires employers to demonstrate financial solvency or provide a surety bond or securities to guarantee payment of benefits, and to submit supporting documents such as audited financial statements and collective bargaining agreements if applicable. By signing this agreement, the employer commits to maintaining compliance, allowing audits, submitting annual financial statements, and paying all obligations under the law. www.FormsWorkflow.com