Form WC-5 "Employee's Claim for Workers' Compensation Benefits" - Hawaii

What Is Form WC-5?

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-5 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-5 "Employee's Claim for Workers' Compensation Benefits" - 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-5
EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS
Instructions
IMPORTANT:
If information provided is incomplete, this claim will not be processed and will be returned to the employee. Please
complete the form in triplicate. Please distribute the form as follows: original and one copy to the appropriate District Office
(see next page) and one copy for employee’s records.
Ensure information indicated is CLEAR, LEGIBLE, COMPLETE AND ACCURATE.
INJURED PERSON:
Name: Enter full, complete name shown on injured person’s social security identification card (no nicknames). Address:
Enter mailing address.
EMPLOYER:
Name: Enter the complete business name of the employer.
Address: Enter full address of employer including city, state and zip code.
INSURANCE CARRIER:
Name: Enter the name of the insurance company that handles workers’ compensation for the employer.
INJURY:
Date of Accident: Enter specific date injury occurred.
Time: Specify time and include a.m. or p.m.
Describe Injury/Illness: How and where did the accident occurred?
Reason for Filing: Specify reason(s) for filing this claim.
WITNESS:
Enter name and address of someone who saw accident, if any.
NOTICE:
Indicate whether you notified your employer of the injury.
ATTENDING PHYSICIAN:
Enter name and address of the physician who treated you for this injury and attach available medical reports to this claim.
REPRESENTED BY:
You may leave this part blank, but if you are represented, enter the name and address of attorney/union agent, or other
representative.
Address: Enter full address of your representative to include city, state and zip code.
SIGNATURE OF CLAIMANT:
Sign your name and date.
ATTACHMENTS: (if available)
(i.e. Physician medical reports, Attorney letter of representation, etc.)
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-5
EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS
Instructions
IMPORTANT:
If information provided is incomplete, this claim will not be processed and will be returned to the employee. Please
complete the form in triplicate. Please distribute the form as follows: original and one copy to the appropriate District Office
(see next page) and one copy for employee’s records.
Ensure information indicated is CLEAR, LEGIBLE, COMPLETE AND ACCURATE.
INJURED PERSON:
Name: Enter full, complete name shown on injured person’s social security identification card (no nicknames). Address:
Enter mailing address.
EMPLOYER:
Name: Enter the complete business name of the employer.
Address: Enter full address of employer including city, state and zip code.
INSURANCE CARRIER:
Name: Enter the name of the insurance company that handles workers’ compensation for the employer.
INJURY:
Date of Accident: Enter specific date injury occurred.
Time: Specify time and include a.m. or p.m.
Describe Injury/Illness: How and where did the accident occurred?
Reason for Filing: Specify reason(s) for filing this claim.
WITNESS:
Enter name and address of someone who saw accident, if any.
NOTICE:
Indicate whether you notified your employer of the injury.
ATTENDING PHYSICIAN:
Enter name and address of the physician who treated you for this injury and attach available medical reports to this claim.
REPRESENTED BY:
You may leave this part blank, but if you are represented, enter the name and address of attorney/union agent, or other
representative.
Address: Enter full address of your representative to include city, state and zip code.
SIGNATURE OF CLAIMANT:
Sign your name and date.
ATTACHMENTS: (if available)
(i.e. Physician medical reports, Attorney letter of representation, etc.)
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
INSTRUCTION SHEET FOR FORM WC-5
EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS
Page 2 of 2
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, In-Person, or via Fax
Department of Labor and Industrial Relations
Disability Compensation Division
,
Oahu
Kauai
Maui
Princess Keelikolani Building
3060 Eiwa Street, Room 202
2264 Aupuni Street, #2
830 Punchbowl Street, Room 209
Lihue, Hawaii 96766
Wailuku, Hawaii 96793
Honolulu, Hawaii 96813
Phone: (808) 274-3351
Phone: (808) 984-2072
Mailing Address:
Fax: (808) 274-3355
Fax: (808) 984-2071
P.O. Box 3769
Honolulu, Hawaii 96812-3769
Phone: (808) 586-9161
Fax: (808) 586-9219
Hawaii
West Hawaii
75 Aupuni Street, Room 108
Ashikawa Building
Hilo, Hawaii 96720
81-990 Halekii Street, Room 2087
Kealakekua, Hawaii 96750
Phone: (808) 974-6464
Fax: (808) 974-6460
If Mailing, Please Mail to This Address:
P.O. Box 49, Kealakelua, Hawaii 96750
Phone: (808) 322-4808
Fax: (808) 322-4813
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-5
EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS
Injured Person
Name
Address
Occupation
Telephone No.
Social Security No.
(
)
Employer
Name
Address
Nature of Business
Telephone No.
(
)
Insurance Carrier
Name
Address
Injury
Date of Accident
Time of Injury
Date Disability Began
a.m.
p.m.
If not on employer’s premises, indicate place where accident occurred
Describe how accident occurred
Describe injury/illness
Reason for filing:
Employer has not filed WC-1
Reopening of old claim
Insurance carrier has not paid benefits
Others (explain)
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
FORM WC-5 EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS
Page 2 of 2
Witness
Name
Work Phone
Home Phone
(
)
(
)
Address
Name
Work Phone
Home Phone
(
)
(
)
Address
Notice
Did you notify the employer of the injury?
Yes
No
If so, when:
How:
Oral
Written
To whom:
Attending Physician
Name
Telephone No.
(
)
Address
I hereby present my claim for compensation for disability resulting from the foregoing injury arising out of and in the
course of my employment and not caused by my intoxication nor by my willful intention to injure myself or another
individual.
I hereby authorize any physician and/or hospital to release any information related to any treatment rendered to me.
Represented by _______________________________
________________________________
ATTORNEY/UNION AGENT
SIGNATURE OF CLAIMANT
Address_______________________________________________________
Date _____________
_______________________________________________________
_______________________________________________________
Auxiliary aids and services are available upon request. Please call: (808) 586-9174; TTY (808) 586-8847; and for neighbor
islands, TTY 1-888-569-6859. A request for reasonable accommodation(s) should be made no later than ten working days
prior to the needed accommodation(s).
It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex,
marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation,
and National Guard participation, be subjected to discrimination, excluded from participation in, or denied the benefits of
the Department’s services, programs, activities, or employment.
Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.
(Rev. 10/05)
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