Form Wc-5 Employee'S Claim For Workers' Compensation Benefits

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STATE OF HAWAII
FORM WC-5
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
(REV 7/92)
DISABILITY COMPENSATION DIVISION
EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS
INJURED
Name _______________________________________________________________________
PERSON
Address _____________________________________________________________________
Occupation ___________________________________________________________________
Phone No. ________________________
Social Security No. _________________________
EMPLOYER
Name _______________________________________________________________________
Address _____________________________________________________________________
Nature of Business ________________
Phone No. _______________________________
INSURANCE Name _______________________________________________________________________
CARRIER
Address _____________________________________________________________________
INJURY
Date of Accident ________________ Time _________ Date Disability Began _______________
If not on employer’s premise, place where accident occurred ____________________________
_____________________________________________________________________________
How did accident occur _________________________________________________________
_____________________________________________________________________________
Describe injury/illness __________________________________________________________
_____________________________________________________________________________
Reason for filing:
Employer has not filed WC-1
Reopening of old claim
Insurance carrier has not paid benefits
Others
Explain _______________________________________________________
_____________________________________________________________________________
WITNESS
Name _______________________________________________________________________
Address _____________________________________________________________________
NOTICE
Did you give employer notice of injury?
Yes
No
If so, when: ___________________________________ How:
Oral
Written
To whom:
___________________________________________________________________
ATTENDING
Name
_____________________________________________________________________
PHYSICIAN
Address _____________________________________________________________________
I hereby present my claim for compensation for disability resulting from the foregoing injury arising out of and
in the course of my employment and not caused by my intoxication nor by my willful intention to injure myself or
another.
I hereby authorize any physician and/or hospital to release any information related to any treatment rendered
me.
Represented by _______________________________
___________________________________
ATTORNEY/UNION AGENT
SIGNATURE OF CLAIMANT
Address ________________________________________________________
Date _______________
________________________________________________________
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