Forms
Forms | Guidelines | Publications
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Workers' Compensation
WC-5 Employee’s Claim for Workers’ Compensation Benefits (Updated 9/23)
WC-5A Dependents’ Claim for Workers’ Compensation
WC-42 Request for Information or Photo Copies
WC-77A Response to Application for Hearing
DC-AF 1 Request for Approval of Attorney’s Fees
Informed Consent for Opioid Prescribed Pills
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.
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-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-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.)