Disability Insurance Program - Attestation Form Survey

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.)

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.

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 Prior to Receiving THAA Access