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
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.
Name: Enter full, complete name shown on injured person’s social security identification card (no nicknames). Address:
Enter mailing address.
Name: Enter the complete business name of the employer.
Address: Enter full address of employer including city, state and zip code.
Name: Enter the name of the insurance company that handles workers’ compensation for the employer.
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.
Enter name and address of someone who saw accident, if any.
Indicate whether you notified your employer of the injury.
Enter name and address of the physician who treated you for this injury and attach available medical reports to this claim.
You may leave this part blank, but if you are represented, enter the name and address of attorney/union agent, or other
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.)
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