Form Hc-4 Health Care Coverage Questionnaire Page 2
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3STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
FORM HC-4 HEALTH CARE COVERAGE QUESTIONNAIRE
Employer Information
Employer Name (Last, First, Middle)
DOL Account No.
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DBA Name, if any
Nature of Business
Address
City
State
Zip Code
Place of Business, if different from above
City
State
Zip Code
HEALTH CARE PLAN(S) – (Chapter 393, Hawaii Revised Statutes)
If health care coverage is not required, please state reason:
Indicate the type(s) of plan(s) you already have or will have:
TYPE 1 – A service type plan which requires the prepaid health care plan contractor, such as Kaiser, to furnish the required health
care benefits.
Name of Health Care Plan Contractor
Plan Name
Group No.
Effective Date
If not under your name, give employer’s or association’s name under which your health care is registered
Classes of Employees Covered by the Plan
No. Covered
TYPE 2 – A reimbursement type plan which requires the prepaid health care contractor, such as HMSA, to defray or reimburse the
expenses of health care. If coverage is by an insurance company, attach a complete copy of the plan for review by the
department.
Name of Health Care Plan Contractor
Plan Name
Group No.
Effective Date
If not under your name, give employer’s or association’s name under which your health care is registered
Classes of Employees Covered by the Plan
No. Covered
TYPE 3 – A plan in which health care benefits are provided according to a collective bargaining agreement. If more than one union,
enter this information in the Additional Information section at the end of the form.
Name of Union
Name of Health Care Plan Contractor
Name or Number of Plan
No. Covered
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(Rev. 10/05)
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