State Of Hawaii Form Wc-5 - Employee'S Claim For Workers' Compensation Benefits Page 3
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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
FORM WC-5
EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS
Injured Person
Name
Address
Occupation
Telephone No.
Social Security No.
(
)
Employer
Name
Address
Nature of Business
Telephone No.
(
)
Insurance Carrier
Name
Address
Injury
Date of Accident
Time of Injury
Date Disability Began
a.m.
p.m.
If not on employer’s premises, indicate place where accident occurred
Describe how accident occurred
Describe injury/illness
Reason for filing:
Employer has not filed WC-1
Reopening of old claim
Insurance carrier has not paid benefits
Others (explain)
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(Rev. 10/05)
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