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Workers’ Compensation

WC-1 Employer’s Report of Industrial Injury (effective July 1, 2022)

WC-2 Physician’s Report

Informed Consent for Opioid Prescribed Pills

WC-5 Employee’s Claim for Workers’ Compensation Benefits (Updated 9/23)

WC-5A Dependents’ Claim for Workers’ Compensation

WC-14 Employee’s Wage Report

WC-21 Application for Self-Insurance

WC-36 This form can only be completed by Workers’ Compensation carriers. Contact your carrier for information.

WC-42 Request for Information or Photo Copies

WC-77 Application for Hearing

WC-77A Response to Application for Hearing

DC-AF 1 Request for Approval of Attorney’s Fees

Hawaii’s Workers’ Compensation Treatment Plan

Temporary Disability Insurance (TDI)

For employees:

TDI-45 Claim for Disability Benefit 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 and Agreement

TDI-62 This form can only be completed by TDI carriers. Contact your TDI carrier for more information.

Prepaid Health Care (PHC)

HC-5 for 2024 Employee Notification to Employer

HC-5 for 2023 Employee Notification to Employer

For employers:

HC-4 Health Care Coverage Questionnaire

HC-6 Small Employers Subject to PHC/Employer’s Request for Premium Supplementation

HC-15 This form can only be completed by PHC plan contractors.  Contact your PHC plan contractor for information.

HC-61 Application for Self-Insurance Authorization

For health care contractors:

HC-7 Application for Plan Review

HC-7(a-1) “Reimbursement” type plans (A summary of benefits of the prevalent PPO plan.)

HC-7(a-2) “Service” type plans (A summary of benefits of the prevalent HMO plan.)

General Forms

DC-54 Complaint Form

Disability Compensation Division

TIẾNG VIỆT: VIETNAMESE

Bạn có cần giúp đỡ bằng ngôn ngữ khác không ? Chúng tôi se yêu cầu một người thông dịch viên miễn phí cho bạn. Gọi (808-586-9151) nói cho chúng tôi biết bạn dùng ngôn ngữ nào.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

TAGALOG: TAGALOG

Kailangan ba ninyo ng tulong sa ibang lengguwahe? Ikukuha namin kayo ng libreng tagasalin. Tumawag sa (808-586-9151) para sabihin kung anong lengguwahe ang nais ninyong gamitin.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

ภาษาไทย: THAI

คุณต้องการความช่วยเหลือทางด้านภาษาหรือไม่ ทางเราจะจัดหาล่ามฟรีให้คุณ โทรที่เบอร์ (808-586-9151) และบอกเราว่าคุณพูดภาษาอะไร

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

ESPAÑOL: SPANISH

¿Necesita ayuda en otro idioma? Nosotros le ayudaremos a conseguir un intérprete gratuito. Llame al (808-586-9151) y diganos que idioma habla.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

GAGANA SAMOA: SAMOAN

E te mana’o mia se fesosoani i se isi gagana? Matou te fesosoani e ave atu fua se faaliliu upu mo oe. Vili mai i le numera lea (808-586-9151) pea e mana’o mia se fesosoani mo se faaliliu upu.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

KAJIN MAJÔL: MARSHALLESE

Kwoj aikuij ke jiban kin juon bar kajin? Kim naj lewaj juon am dri ukok eo ejjelok wonen. Kirtok (808-586-9151) im kwalok non kim kajin ta eo kwo melele im kenono kake.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

한국어: KOREAN

다른언어로 도움이 필요하십니까? 저희가 무료로 통역을 제공합니다. (808-586-9151) 로 전화해서 사용하는 언어를 알려주십시요

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

日本語 (JAPANESE)

貴方は、他の言語に、助けを必要としていますか ? 私たちは、貴方のために、無料で 通訳を用意で きます。電話番号の (808-586-9151) に、電話して、私たちに貴方の話されている言語を申し出てください。

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

ILOKANO: ILOCANO

Masapulyo kadi ti tulong iti sabali a pagsasao? Ikkandakayo iti libre nga paraipatarus. Awaganyo ti (808-586-9151) tapno ibagayo kadakami no ania ti pagsasao nga ar-aramatenyo.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

ʻŌLELO HAWAIʻI: HAWAIIAN

Makemake `oe i kokua i pili kekahi `olelo o na `aina `e? Makemake la maua i ki`i `oe mea unuhi manuahi. E kelepona (808-586-9151) `oe ia la kaua a e ha`ina `oe ia la maua mea `olelo o na `aina `e.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

KAPASEN CHUUK: CHUUKESE

En mi niit alilis lon pwal eu kapas? Sipwe angei emon chon chiaku ngonuk ese kamo. Kokori (808-586-9151) omw kopwe ureni kich meni kapas ka ani.

You have the right to an interpreter
at no cost to you.

Disability Compensation Division

中文 – CHINESE Mandarin

您需要其它語言嗎?如有需要, 請致電 (808-586-9151), 我們會提供免費翻譯服 (Traditional)

您需要其它语言吗?如有需要,请致电 (808-586-9151), 我们会提供免费翻译服务 (Simplified)

You have the right to an interpreter at no cost to you.

Disability Compensation Division

中文 – CHINESE: Cantonese

您需要其它語言嗎?如有需要, 請致電 (808-586-9151), 我們會提供免費翻譯服務 (Traditional)

您需要其它语言吗?如有需要,请致电 (808-586-9151), 我们会提供免费翻译服务 (Simplified)

You have the right to an interpreter at no cost to you.

Disability Compensation Division

VISAYAN: CEBUANO

Gakinahanglan ka ba ug tabang sa imong pinulongan? Amo kang mahatagan ug libre nga maghuhubad. Tawag sa (808-586-9151) aron magpahibalo kung unsa ang imong sinulti-han.

You have the right to an interpreter at no cost to you.