Temporary Disability Insurance
Temporary Disability Insurance (TDI) is a “wage replacement” program that pays benefits to partially replace loss of wages due to off-the-job sickness or injury.
Andrea Carter
Accumulator 15
Accumulator 15 is a limited-pay whole life insurance policy requiring fifteen years of premiums and provides guaranteed paid-up life insurance protection for your entire lifetime.
Group Life Application for Disability Benefits Form
The statement for the Group Life Application for Disability Benefits Form should be filled out by the employee. An Attending Physician's signature is needed. The Physician can then mail the completed form to PGL.
Group Accelerated Death Benefit Claim Form
This is a claim for Group Accelerated Death Benefit Claim Form. The Insured/Claimant, Employer/Policyholder, and an Attending Physician are needed to complete the form.
Group Accidental Death & Dismemberment (AD&D) Claim Form
This is a claim for Group Accidental Dismemberment or Loss of Sight Benefits. A Physician's Statement is needed for the form's completion.
Group Life Death Claim Form
When submitting this form, also submit the insurance Certificate of Coverage, an original Death Certificate, the original Enrollment Card, and all Change of Beneficiary forms.
Instructions to Complete TDI Claim Form
Employers should complete this form with help from their employee and their employee's physician.
Temporary Disability Insurance (TDI) Claim Form
The Temporary Disability Insurance (TDI) Claim Form will need a Claimant's Statement, Employer's Statement, and Doctor's Statement to be completed.
Instructions to Complete Employer’s TDI Premium Statement 2018-2019
These are the instructions to complete the Employer's Temporary Disability Insurance (TDI) Premium Statement. If needed, they're downloadable and printable.
Beneficiary and/or Name Change Form
This is the Beneficiary and/or Name Change Form. If needed, complete the form and submit to PGL. A copy will be provided to your employer. Please obtain copy from your employer for your personal record.