Temporary Disability Insurance (TDI) Application for Benefits Form
Click here to download the "paper" application form for TDI benefits
You will need Adobe Reader to access the application.
Please complete every question so that you will not experience delays in filing for benefits. Please do not file multiple applications for the same illness/injury as this will also delay processing your claim.
We have eliminated the payment of TDI benefits by paper checks. You have two different benefit payment options; Direct Deposit or Electronic Payment Card (EPC) (similar to a debit card).
- If you select the Direct Deposit method, please complete the direct deposit form and mail it with your TDI application to the address below.
- If you select the Electronic Payment Card (EPC), do not send in a direct deposit form. The EPC card will arrive in the mail in a plain white envelope. Please be sure to read the instructions to avoid any ATM or bank charges. Visit the TDI EPC website for more information.
Please print and complete the application form. Attach the direct deposit form (if you choose that option) and mail to:
Temporary Disability Insurance
P.O. Box 20100, Cranston, RI 02920-0941
Temporary Disability Insurance
P.O. Box 20100, Cranston, RI 02920-0941
