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A.9720

Attachment 6

MEMORANDUM

TO:

WC Coordinator

FROM:

___________________________

Date of Injury:

________________________

Employee-Claimant Name (print)

SUBJECT:

Sick/Vacation Pay During Receipt of Workers’ Compensation Disability Benefits

I understand that there is a three (3) calendar day wait period, pursuant to Chapter 386, HRS, before I am eligible for receipt of workers’

compensation (WC) wage loss replacement benefits.

Therefore, I must account for these days of absence due to work-related

injury/illness by using personal leave (sick, vacation, or leave without pay). I further understand that the WC wage loss replacement shall

be paid only for those periods of authorized temporary total disability (TTD) or temporary partial disability (TPD) at the rate of 2/3 of my

average weekly wage (AWW) which shall not be more than the specified State maximum AWW and not less than the specified State

minimum AWW. I further understand that the University permits me to use my accrued sick and vacation leave with the intent to provide

me with income additional to my WC wage loss replacement, in accordance with applicable H.R.S. provisions. Finally, I understand that

WC wage loss replacement will be sent directly to me at the mailing address shown on the UH Form 79, Report of Work-Related

Injury/Illness, or as otherwise reported. With this understanding, I hereby make the following election which shall be effective to the date

my disability ends, unless superseded by a subsequent UH Form 41 (OHR), Sick/Vacation Pay During Workers’ Compensation Disability

Benefits:

Option 1: _____

WC Benefits Only (66 2/3% of weekly wages, not to exceed the specified State maximum)

I elect not to supplement my TTD or TPD benefits with available accrued sick and/or vacation leave while

absent due to work-related disability. I understand that I will be placed on Leave Without Pay status for the

duration of authorized absence due to work-related disability. I understand that no voluntary deductions can be

made from my workers’compensation wage replacement benefits, and I will be responsible for making direct

payments to the respective payees.

Option 2: _____

WC Benefits + Sick/Regular Pay = Regular Salary (100%)

I elect to supplement my WC wage loss replacement benefits with available accrued sick leave credits. The

total of my WC wage replacement benefits plus salary payments (supplemental sick leave credits and/or

regular pay) shall equal my regular salary. I understand that my sick leave credits will used on a pro-rata basis.

Do not use my available accrued vacation leave credits. If I do not have sufficient accrued sick leave credits to

receive a sum equal to my full salary, I will receive an amount equal to workers’compensation benefits plus

regular pay for any days worked plus available sick leave pay.

Option 3: _____

WC Benefits + Sick/Vacation/Regular Pay = Regular Salary (100%)

I elect to supplement my WC wage replacement benefits with available accrued sick and vacation leave credits.

The total of my WC wage replacement benefits plus salary payments (supplemental sick and/or vacation leave

credits and/or regular pay) shall equal my regular salary. I understand that my sick and/or vacation leave

credits will be used on a pro-rata basis. I further understand that my vacation leave credits will only be used if

my available accrued sick leave credit balance is insufficient or if my available accrued vacation leave credit

balance will be in excess of the maximum year end accrued balance of 720 hours .

I understand that no deductions can be made from my WC benefit payments, other than for statutory ERS contributions as indicated

below. All voluntary deductions and reductions shall be from my vacation/sick leave payments. As such, should my vacation/sick leave

payments be insufficient to cover all voluntary deduction items, I shall make payments directly to the respective payees.

STATUTORY ERS DEDUCTION FROM WAGE LOSS REPLACEMENT BENEFITS: In accordance with HRS §78-25, I am a member

of the ERS Contributory/Hybrid retirement plan and hereby acknowledge

(initial) that the Employer and/or TPA/IC are

required to deduct the applicable statutory ERS contribution from my wage loss replacement benefits and appropriately deposit such

amounts to the ERS.

I understand that I am responsible for timely notifying my department and the TPA/ IC of any changes to my mailing address. With my

signature below, I hereby authorize the WC Coordinator of my college to process applicable On-Line Leave Request entry in compliance

with my election as shown above. A photocopy of this form shall be considered as effective and valid as the original.

_____________________________________________

________________

Signature of Employee-Claimant

Date

(Invalid without signature)

Original:

First Insurance

Copies:

WC Coordinator, UH Payroll (to be attached to first submission of UH Form 78) & Office of Risk Management

UH Form 41 (rev. 06/2015)

Uh Form 41 - Memorandum - Sick/vacation Pay During Receipt Of Workers' Compensation Disability Benefits

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