INSTRUCTIONS TO CLAIMANT
1.
Give specific reasons for appealing for each item of denial checked on the face of this form.
2.
Attach any medical evidence and/or employment records that will support your appeal.
3.
Complete all copies of this form received from your employer or insurance company.
4.
Mail two copies promptly to: Department of Labor and Industrial Relations
Disability Compensation Division
P.O. Box 3769
Honolulu, Hawaii 96812-3769
5.
Retain one copy for your record.
6.
File the Claimant’s Appeal within 20 days after the date of the receipt of this notice.
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.
CLAIMANT’S APPEAL
My claim for Disability Benefits has been denied and I hereby appeal such denial, for the following reason(s):
(Answer only with respect to items of denial checked on face of this form.)
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Date Notice of Denial of Claim for Disability Benefits received by Claimant: __________________________________
Claimant's Signature _________________________________________________ Date: _____________________________