Disability Insurance Program - Attestation Form Survey

1.First Name of DIP/RTW Representative with THAA Access:(Required.)

2.Last Name of DIP/RTW Representative with THAA Access:(Required.)

3.Email Address of DIP/RTW Representative with THAA Access:(Required.)

4.Employing Organization:(Required.)

5.Read the statement below and check the box to attest to it:(Required.)

As the HR/Payroll Lead or Supervisor, I confirm that the DIP/RTW Representative noted on this form has completed all the required readings and training needed after receiving THAA access.

6.First Name of HR/Payroll Lead or Supervisor Completing the Form:(Required.)

7.Last Name of HR/Payroll Lead or Supervisor Completing the Form:(Required.)

8.Job Title of HR/Payroll Lead or Supervisor Completing the Form:(Required.)

9.Email Address of HR/Payroll Lead or Supervisor Completing the Form:(Required.)

Disability Insurance Program - Attestation Form

Required Steps to Complete After Receiving THAA Access