Application For Certificate Of Compliance With Section 3-122-112 printable pdf download

Application For Certificate Of Compliance With Section 3-122-112

STATE OF HAWAII

DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

INSTRUCTION SHEET FOR FORM LIR#27 APPLICATION FOR

CERTIFICATE OF COMPLIANCE WITH SECTION 3-122-112, HAR

Purpose

The State and County Government Purchasing Offices require vendors to submit a completed copy of this certificate.

Page 1 of this application becomes the Certificate of Approval. Facsimiles and copies of this approval form are proof of

compliance. This certificate applies to the Hawaii Unemployment Insurance, Workers’ Compensation, Temporary

Disability Insurance, and Prepaid Health Care programs.

Applications are available at the addresses below and can be downloaded from the Department of Labor and Industrial

Relations’ (DLIR) web site . From the DLIR web site, Form LIR#27 is listed under the

Unemployment Insurance Division and Disability Compensation Division.

DO NOT SUBMIT THIS PAGE

Approved, Not Applicable, or Pending certificates are valid for 6 months.

Date submitted to the DLIR _____________ (for your use)

Allow up to a total of seven (7) business days for processing.

FILING INSTRUCTIONS FOR THE

APPLICATION FOR CERTIFICATE OF COMPLIANCE WITH SECTION 3-122-112, HAR

Form LIR#27 (Rev. 10/05)

SUBMIT (mail, fax, or deliver) completed application only to the Department of Labor and Industrial Relations,

Unemployment Insurance Division*.

*Unemployment Insurance Division

830 Punchbowl Street, Room 437

Honolulu, Hawaii 96813

Ph: (808) 586-8926

Fax: (808) 586-8929

INQUIRIES regarding the status of an application submitted seven (7) business days earlier should be directed to the

Disability Compensation Division** (Workers’ Compensation, Temporary Disability Insurance, and Prepaid Health

programs).

**Disability Compensation Division

830 Punchbowl Street, Room 209

Honolulu, Hawaii 96813

Ph: (808) 586-9200

Fax: (808) 586-9206

The Approved, Not Applicable, or Pending certificate of approval will be faxed to the applicant by the Disability

Compensation Division. Non-compliant applicants will receive Form LIR#27A instructing the applicant to contact the

appropriate program(s).

Visit our Website at for ALL interactive and downloadable forms.

(Rev. 10/05)

Application For Certificate Of Compliance With Section 3-122-112