I hereby present my claim for compensation for disability resulting from the foregoing injury/illness arising out of and in the course of my employment and not caused by my intoxification nor by my willful intention to injure myself or another individual.

Hawaii’s Workers’ Compensation Treatment Plan. The following forms must be submitted via portal access: WC-1 Employer’s Report of Industrial Injury; WC-2 Physician’s Report; WC-21 Application for Self-Insurance; WC-36; This form can only be completed by Workers’ Compensation carriers. Contact your carrier for information.

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 …

Claim forms are not available online. Ask your employer for a claim form or contact us if your employer does not have the claim form. FOR EMPLOYERS: TDI-14 Equivalency Tables; TDI-15 TDI Self-Insurer's Plan Certification & Agreement; Prepaid Healthcare (PHC) HC-5 Employee Notification to Employer: 2021; For employers: HC-4 Health Care Coverage ...

WC-5 . This is the form the injured employee submits to the Department of Labor Disability Compensation Division, along with a physician's duly filled out WC-2 whenever the Employer fails to file a WC-1 or otherwise delays the processing of the claim. All claimed injured body parts should be listed. Failing to list all injured body parts and ...

You may file Form WC-5, "Employee's Claim for Workers' Compensation Benefits" with this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you. You may be eligible for Temporary Disability Insurance (TDI) benefits while your WC claim is being investigated.

INSTRUCTION SHEET FOR FORM WC-5 EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS Instructions IMPORTANT: If the information provided is incomplete, this claim will not be processed and will be returned to the employee. Please complete the form and submit to the appropriate District Office (see next page). You may create a copy for

On the ECOMP site you can register for an account, initiate a claim, upload documents, submit forms, and access your case. OWCP's Federal Employees Program has made a variety of forms available online. These forms are only available in PDF format. In order to view and/or print PDF documents you must have a PDF viewer.

Also, includes the “Verification of Partial Unemployment Status” form for employers to compete and return to confirm their employee’s partial unemployment status. This form is due within 5 working days from the date the application is filed.) Workers’ Compensation. WC-1 Employer’s Report of Industrial Injury; WC-2 Physician’s Report