Forms

DLIR Organization Chart

DLIR ASO Organization Chart

Child Labor/Minor’s Work Permit

• CL-1  Child Labor Application (for 14 and 15-year-old minors)
• eCL-3 
 Online Child Labor Application (for 16 and 17-year-old workers)

Employer Forms 

• UC-1 Report to Determine Liability Under the Hawaii Employment Security Law
  Use this form to register your business with the Unemployment Insurance Division when employment commences.
• LIR#27  Application for Certificate of Compliance with Section 3-122-112, HAR
• UC-25  Notification of Changes
• UC-86  Waiver of Employer’s Experience Record
• *UC-B6  Quarterly Wage, Contribution and Employment and Training Assessment Report
  (*Not available online – for assistance, please call 586-8915)

Family Leave

• HFLL-1  An optional form for the certification of a serious health condition by a health care provider

Hawaii Labor and Industrial Relations Appeals Board

• LIRAB 1 – Initial Conference Statement
• LIRAB 2 – Notice of Non Hearing Motion
• LIRAB 3 – Notice of Hearing
• LIRAB 4 – Unnamed Witness Identification
• LIRAB 5 – Live Witness Identification
• LIRAB 6 – Notice of Appeal
• LIRAB 7 – Stipulation to Continue Conference
• LIRAB 8 – Certificate of Service
• LIRAB 9 – Stipulation for Temporary Remand
• LIRAB 10 – Withdrawal of Appeal
• LIRAB 11 – Stipulation to Dismiss a Party
• LIRAB 12 – Request Order for Transcript of Proceedings
• LIRAB 13 – Designation of Representative
• LIRAB 14 – Stipulation to Waive Discovery and Trial
• LIRAB 15 – Request for Approval of Attorney’s Fee

Hawaii Labor Relations Board 

• HLRB 1  Petition for Certification
• HLRB 2  Petition for Clarification or Amendment of Appropriate Bargaining Unit
• HLRB 3  Petition for Decertification
• HLRB 4  Prohibited Practice Complaint
• HLRB 5  Petition for Review of Refunds
• HLRB 6  Statement of Objections to Conduct of Election
• HLRB 7  Petition Relating to Financial Report of Employee Organization
• HLRB 8  Petition for Determination of CB Unit and Election
• HLRB 9  Petition for Referendum
• HLRB 10  Petition for Decertification
• HLRB 11  Unfair Labor Practice Complaint
• HLRB 12  Petition for Declaratory Ruling
• HLRB 13  Petition for Intervention
• HLRB 14  Application for Issuance of Subpoenas
• HLRB 15  Subpoena
• HLRB 16  Subpoena Duces Tecum
• HLRB 17  Sample Format for HIOSH Initial Conference Statement

Hawaii Occupational Safety & Health 

• Advisory Board Application Form
• Boilers & Elevators
• Certificate of Fitness for Explosives
• Certified Safety and Health Professional
• Hoisting Machine Operators Advisory Board

Hawaii Civil Rights Commission

• FORM PCQ-Employment: Pre-Complaint Questionnaire Employment
• FORM PCQ-Access to State/Funded Services: Pre-Complaint Questionnaire
• FORM PCQ-Public Accommodation: Pre-Complaint Questionnaire
• FORM PCQ-Real Property Transaction: Pre-Complaint Questionnaire

Personnel

• Internal Complaint Procedure / Form

Prepaid Healthcare

• HC-4  Health Care Coverage Questionnaire
• HC-5  Employee Notification to Employer
• HC-6  Small Employers Subject To PHC / Employer’s Request for Premium Supplementation
• HC-61  Application For Self-Insurance Authorization

State Fire Council

• SFC 1-99  Fire Inspection Report

Temporary Disability Insurance

• TDI-14  Equivalency Tables
• TDI-15  TDI Self-Insurer’s Plan Certification & Agreement

Unemployment Insurance (Employers)

• LIR#27  Application for Certificate of Compliance with Section 3-122-112, HAR (Use this form to request a tax clearance from the Department of Labor & Industrial Relations for Professional Service Awards)
• UC-1 Report to Determine Liability Under the Hawaii Employment Security Law
  Use this form to register your business with the Unemployment Insurance Division when employment commences.
• *UC-B6  Quarterly Wage, Contribution and Employment and Training Assessment Report  (*Not available online – for assistance, please call 586-8915 or 586-8916)
• UC-25  Notification of Changes (Use this form to notify the Unemployment Insurance Division of any changes to an employer’s address or status of business)
• UC-336  Election By Family Owned Corporation to be Excluded from coverage Under Section 383-7(20), HRS (Use this form to elect exclusion from unemployment insurance coverage of a family-owned corporation)
• UC-347 Notification of Acquisitions or Transfers (Use this form to report acquisitions or transfers in accordance with Section 383-66(b), HRS, if there is substantially common ownership, management or control between employing units or an acquisition or transfer made between an employing unit and a person who is not an employing unit.  The department will determine substantially common ownership, management or control.  All parties involved in the acquisition or transfer must file the form separately.
• UC-348 Partial Unemployment Information (Information for claimants and employers on the definition, assessment and determination of partial unemployment. 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.)
• UC-86  Waiver of Employer’s Experience Record (Use this form to request acquisition of the experience record of a predecessor employer)
• Self-Financing for Non-Profit Organizations (NPO)
  Non-profit organizations (religious, charitable, and educations) qualifying for income tax exemption under the Section 501(c)(3) Internal Revenue Code may apply for exemption from paying contributions by requesting self-financing status under provisions of Chapter 383-62(d) of the Hawaii Employment Security Law.  Indian tribes or tribal units may elect to be self-financing.

Unemployment Insurance (UI Claimants)

• UC-BP-1SAB
 Manual application form to file for State Additional Benefits (SAB) 2016. This program begins September 4, 2016 and ends October 28, 2017.
• UC-253  Record of Contacts Made for Work.
• UC-161(a)  Instructions for Partial and Part-Total Claimant’s Filing on the Web. In addition of filing your weekly or biweekly claim certification, your employer must file “Weekly Report of Low Earnings” to verify your earnings, availability for work and continued employment for each week that you claim.
• UC-226  Verification of Registration with a Referring Union.  If you report that you will obtain work through a referring union, have an authorized union official complete and submit this form to your local claims office within 7 calendar days after filing your claim.
• UC-275  Request for Withdrawal of Claim
• UC-348  Partial Unemployment Information (Information for claimants and employers on the definition, assessment and determination of partial unemployment. 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
• WC-5  Employee’s Claim for Workers’ Compensation Benefits
• WC-5A  Dependents’ Claim for Compensation
• WC-14  Employee’s Wage Report
• WC-21  Application for Self-Insurance Authorization
• WC-77  Application for Hearing
• WC-77a  Response to Application for Hearing
• LIR#27  Application for Certificate of Compliance with Section 3-122-112, HAR