Disability Insurance Program - Attestation Form

Required Steps to Complete After Receiving THAA Access

* Required Questions

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* 1. First Name of DIP/RTW Representative with THAA Access:

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* 2. Last Name of DIP/RTW Representative with THAA Access:

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* 3. Email Address of DIP/RTW Representative with THAA Access:

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* 4. Employing Organization:

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* 5. Read the statement below and check the box to attest to it:

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.

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* 6. First Name of HR/Payroll Lead or Supervisor Completing the Form:

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* 7. Last Name of HR/Payroll Lead or Supervisor Completing the Form:

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* 8. Job Title of HR/Payroll Lead or Supervisor Completing the Form:

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* 9. Email Address of HR/Payroll Lead or Supervisor Completing the Form: