Form WC-21 "Application for Self-insurance Authorization" - Hawaii

What Is Form WC-21?

This is a legal form that was released by the Hawaii Department of Labor & Industrial Relations - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2005;
  • The latest edition provided by the Hawaii Department of Labor & Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC-21 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Labor & Industrial Relations.

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Download Form WC-21 "Application for Self-insurance Authorization" - Hawaii

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STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
INSTRUCTION SHEET FOR FORM WC-21
APPLICATION FOR SELF-INSURANCE AUTHORIZATION
Instructions
Please completely fill out the WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION FORM.
The Delivery Information section below lists various delivery options. Please select the most convenient method and
submit the completed form accordingly.
Please remember to sign and date the form before submitting it.
Delivery Information
Delivery by U.S. Mail
Department of Labor and Industrial Relations
Disability Compensation Division
,
P.O. Box 3769, Honolulu, Hawaii 96812-3769
Delivery In-Person
Department of Labor and Industrial Relations, Disability Compensation Division
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
Delivery via Fax
Department of Labor and Industrial Relations, Disability Compensation Division
(808) 586-9219
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
INSTRUCTION SHEET FOR FORM WC-21
APPLICATION FOR SELF-INSURANCE AUTHORIZATION
Instructions
Please completely fill out the WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION FORM.
The Delivery Information section below lists various delivery options. Please select the most convenient method and
submit the completed form accordingly.
Please remember to sign and date the form before submitting it.
Delivery Information
Delivery by U.S. Mail
Department of Labor and Industrial Relations
Disability Compensation Division
,
P.O. Box 3769, Honolulu, Hawaii 96812-3769
Delivery In-Person
Department of Labor and Industrial Relations, Disability Compensation Division
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
Delivery via Fax
Department of Labor and Industrial Relations, Disability Compensation Division
(808) 586-9219
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
FORM WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION
To the Director of the Department of Labor and Industrial Relations (DLIR):
The undersigned, an employer, hereby makes application for permission to operate as a self-insurer pursuant to Chapter
386, Hawaii Revised Statutes, as amended, and in support of such application submits the following information:
1. Name of Applicant (if a corporation, show name exactly as it appears in the Charter or Articles of Incorporation.)
Please Check:
DOL Acct No
Corporation
Partnership
Sole Proprietorship
Other
-
-
2. Mailing Address in Hawaii
3. Location of other business locations in Hawaii
4. Nature of Business
5. Number of Employees in Hawaii
6. Average monthly payroll in Hawaii for the past year
7. If a Subsidiary Company:
(a) Name of Parent Company
Address
(b) Parent Company’s Percentage of Stock Ownership
8. Will any of the applicant’s operations be conducted under a name other than that shown in (1) above? _____ If yes, please provide
(a) Name
(b) Address
(c) Nature of Business
9. Date of Commencement of Business in Hawaii
10. Number of Hawaii employees to be covered by the proposed self-insurance plan
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
FORM WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION
Page 2 of 4
11. Enter below the net profit or loss after taxes for the last five years.
Year
Amount
20
$
20
$
20
$
20
$
20
$
12. If this application is approved, it is proposed that the deposit of security required will be in the form of: (check one)
Surety Bond
Approved Securities
13. Individual who will sign or be responsible for obtaining signatures on the Self-Insurer’s Annual Report and the surety
bond or Agreement and Undertaking.
(a) Name
(b) Title
(c) Address
(d) Telephone No.
(e) Fax No.
(
)
(
)
14. Complete the following relative to the applicant’s Hawaii Workers’ Compensation policies.
(a) Name
(b) Title
(c) Address
(d) Telephone No.
(e) Fax No.
(
)
(
)
Premium Before
Experience
Year
Payroll
Losses Incurred
Loss Ratio
Dividend
Modification
15. Has an application for workers’ compensation insurance ever been rejected or a policy cancelled?
Yes
No
If yes, (a) On what date?
(b) Why?
(c) Name of Carrier
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
FORM WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION
Page 3 of 4
16. Individual in your organization who will be responsible for your self-insurance program:
(a) Name
(b) Title
(c) Address
(d) Telephone No.
(
)
17. Claims administration functions (claims adjusting, etc.) will be performed by:
(a) Self Insurer’s Own Organization
(b) Outside of the Organization
(c) Other (explain)__________________________
18. Claims Administration:
(a) If by self-insurer’s own organization:
Name of Administrator
Title
Address
Telephone No.
(
)
(b) If by an outside organization:
Name of Organization
Name of Administrator
Address
Telephone No.
(
)
(c) Will the administrator have the authority to promptly provide all benefits due?
Yes
No
If no, explain limitations
19. Will the claims administration functions be performed at more than one location?
Yes
No
If yes, on a separate page, please provide all information requested in item 18 above for each adjusting location.
20. Individual who will prepare the consolidated self-insurer’s annual report.
Name
Title
Address
Telephone No.
Fax No.
(
)
(
)
21. Self-insurer’s annual report forms are to be mailed to: (check appropriate item)
(a) The individual administrators
(b) Consolidator of annual report
(c) Other (specify)____________________________
22. Will applicant’s Workers’ Compensation self-insurance program be supplemented by an insurance policy?
Yes
No
If so, a copy of the policy and any change in coverage should be filed with the Director of the DLIR.
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
FORM WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION
Page 4 of 4
23. At the date of this application, is there any litigation or proceeding pending or threatened, the result of which might
substantially adversely affect the financial condition, business, or operations of the applicant or any of its subsidiaries?
Yes
No
If yes, explain (If more space is needed, please attach another sheet.)
24. Required Attachments
(a) A current copy of the applicant’s Independent Audit Report, complete with all schedules and notes, or upon written
application, such other financial information as may be acceptable to the Director of the DLIR.
(b) If the report of the financial condition is dated more than twelve (12) months prior to the date of this application, the
Director of the DLIR may require interim financial statements (Balance Sheet and Profit and Loss Statement)
certified by the appropriate financial officers and dated not less than three (3) months from the date of this
application.
(c) If a Corporation:
A copy of the resolution of the applicant corporation’s Board of Directors authorizing the filing of an application for
a certificate of consent to self-insurance and execution of the instrument of undertaking in furnishing security if
required.
Dated:________________________________________ , 20_____
_________________________________________________
By:_________________________________________________
(Owner, Partner or Officer)
State of _______________________________________)
)
)
SS
)
______________________________________________)
______________________________________________, being first duly sworn, on oath states:
That he/she is the __________________________________ of ______________________________________________
(Owner, Partner or Officer)
Name of Business
making this application to operate as a self-insurer under the Workers’ Compensation Law of the State of Hawaii, that
he/she has read the above application and the facts contained therein are true, that all allegations made in such
application are for the purpose of inducing the Director of the DLIR to grant such application; and that the duties and
responsibilities of the applicant under said law will be fully carried out at the time and in the manner therein provided.
Subscribed and sworn before me this _____ day of _____________________, 20_____.
_______________________________________
Notary Public, ______________ Judicial Circuit
State of _____________________________
My commission expires ____________________
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
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