Disability Insurance Program - Attestation Form

Required Steps to Complete Prior to Receiving THAA Access

* Required Questions

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

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

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

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4. Employing Organization: (Required.)

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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 to receive THAA access. I understand that after the DIP/RTW Representative receives access to THAA by SBO, that there are required steps they need to complete within 60 calendar days of receiving THAA access. I will ensure the DIP/RTW Representative completes the required steps within 60 calendar days. I understand that if the required steps are not completed within the allotted timeframe, that THAA access may be terminated for the DIP/RTW Representative.

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

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

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

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

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

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

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

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* 4. Employing Organization: (Required.)

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

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

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

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

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

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

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

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

4. Employing Organization: (Required.)

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

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.)