State Of Hawaii Form Wc-5 - Employee'S Claim For Workers' Compensation Benefits
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4STATE 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
Instructions
IMPORTANT:
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.
INJURED PERSON:
Name: Enter full, complete name shown on injured person’s social security identification card (no nicknames). Address:
Enter mailing address.
EMPLOYER:
Name: Enter the complete business name of the employer.
Address: Enter full address of employer including city, state and zip code.
INSURANCE CARRIER:
Name: Enter the name of the insurance company that handles workers’ compensation for the employer.
INJURY:
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.
WITNESS:
Enter name and address of someone who saw accident, if any.
NOTICE:
Indicate whether you notified your employer of the injury.
ATTENDING PHYSICIAN:
Enter name and address of the physician who treated you for this injury and attach available medical reports to this claim.
REPRESENTED BY:
You may leave this part blank, but if you are represented, enter the name and address of attorney/union agent, or other
representative.
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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(Rev. 10/05)
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