Form Hc-4 Health Care Coverage Questionnaire Page 3
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3FORM HC-4 HEALTH CARE COVERAGE QUESTIONNAIRE
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TYPE 4 – A self-insured plan with satisfactory proof of solvency and financial ability to defray or reimburse health care benefits.
Attach copies of the plan and employer’s audited financial statements.
Name of Health Care Plan Administrator
Plan No. or Name
Group No.
Effective Date
Classes of Employees Covered by the Plan
No. Covered
Indicate the number of employees you feel will be exempted from coverage and the reason(s) for their exemption.
No. of Employees
Reason for Exemption
Works less than 20 hours a week
Covered as a dependent under a qualified health care plan
Covered by primary employer
Covered by a State or Federal health care plan
Covered by State-governed medical assistance or the employee is a public assistance recipient
Other coverage obtained from ________________________________ (name of health care contractor) which
meets the Prepaid Health Care (PHC) Law (attach copy of plan and send to Disability Compensation Division).
Other __________________________________________________________________________________
If applicable, indicate your share and the employee’s share of the premium cost. (Note: You cannot deduct more than
1.5% of the employee’s gross wages up to one-half of the monthly premium. If the employee’s share is less than half, you
must pay the remaining portion.)
Total monthly premium cost per employee for employee only coverage
Employee Pays
Employer Pays
$
$
$
Total monthly premium cost for employee and dependents coverage
Employee Pays
Employer Pays
$
$
$
Additional Information (if more space is needed, please attach another sheet)
Signature
Title
Date
Print Name
Telephone No.
Fax No.
(
)
(
)
Auxiliary aids and services are available upon request. Please call: (808) 586-9188; TTY (808) 586-8847; and for neighbor
islands, TTY 1-888-569-6859. A request for reasonable accommodation(s) should be made no later than ten working days
prior to the needed accommodation(s).
It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex,
marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation,
and National Guard participation, be subjected to discrimination, excluded from participation in, or denied the benefits of
the Department’s services, programs, activities, or employment.
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(Rev. 10/05)
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