Form Wc-5 Employee'S Claim For Workers' Compensation Benefits Page 2
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1
2INSTRUCTIONS FOR COMPLETING WC-5
“EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS”
IMPORTANT:
This claim will not be processed and will be returned if information provided is incomplete. Complete in triplicate. Keep one copy and
send the original and one copy to your district office shown on the bottom of the page.
Ensure information indicated is CLEAR, LEGIBLE, COMPLETE AND ACCURATE.
INJURED PERSON:
Name:
Enter name shown on your social security identification card (no nicknames).
Address: Enter mailing address.
EMPLOYER:
Name:
Enter complete business name of employer.
Address: Enter full address of employer to include city, state and zip code.
INSURANCE CARRIER:
Name:
Enter the name of the insurance company that handles workers’ compensation for your employer.
INJURY:
Date of Accident:
Enter specific date injury occurred.
Time:
Specify time and whether a.m. or p.m.
Describe injury/illness: How and where accident occurred?
Reason for filing:
Specify reason for filing claim.
WITNESS:
Enter name and address of someone who saw accident, if any.
NOTICE:
Did you tell your employer you got hurt?
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 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)
Physician medical reports
Attorney letter of representation
HONOLULU OFFICE
HAWAII DISTRICT OFFICE
WEST HAWAII DISTRICT OFFICE
P.O. Box 3769
State Office Building
P.O. Box 49
Honolulu, Hawaii 96812-3769
75 Aupuni Street, #108
Kealakekua, Hawaii 96750
Hilo, Hawaii 96720
MAUI DISTRICT OFFICE
KAUAI DISTRICT OFFICE
State Office Building
State Office Building
2264 Aupuni Street, #2
3060 Eiwa Street, #202
Wailuku, Hawaii 96793
Lihue, Hawaii 96766-1887
Auxiliary aids and services are available upon request. Please call (808) 586-9161; 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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