WC-1 EMPLOYER S REPORT OF INDUSTRIAL INJURY

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1 Every work injury to an employee causing abscence for one day or more or which requires medical services other than first aid treatment must be reported within 7 working days after the injury. Failure to report promptly is a misdemeanor punishable by not more than a $5,000 fine. (Sec , H.R.S. NOTIFY THE DIVISION IMMEDIATELY IF INJURY RESULTS IN DEATH.) EVERY QUESTION MUST BE ANSWERED FULLY TO AVOID FURTHER CORRESPONDENCE. The law requires the employer to furnish the injured employee a copy of this report. WC-1 EMPLOYER S REPORT OF INDUSTRIAL INJURY CASE NUMBER indentification section note: do not write in shaded blocks EMPLOYEE NAME LAST FIRST M.I. SOC SEC NO DATE OF BIRTH SEX MARITAL STATUS DATE RECEIVED MALE MARRIED MM / DD / YY FEMALE SINGLE MM / DD / YY ADDRESS ADDITIONAL ADDRESS INFORMATION (C/O) CITY STATE ZIP CODE PHONE OCCUPATION DATE HIRED YRS EMP D CODE DEPARTMENT PAYROLL COMP OCC CODE CLASS CODE MM / DD / YY REGISTERED EMPLOYER DBA ADDRESS CITY STATE ZIP CODE PHONE NATURE OF BUSINESS DATE INJURY/ILLNESS REPORTED DATE OF INJURY/ILLNESS PREFAB DOLNUMBER DBA MM / DD / YY MM / DD / YY WC-2 WC-5 DETAIL OF INJURY / ILLNESS TIME OF INJURY/ILLNESS TIME OF I/I CODE PLACE OF I/I IF DIFFERENT FROM RMPLOYER S MAILING ADDRESS CITY STATE ON EMPLOYER S INDUSTRIAL CODE PREMISES AM PM YES NO HOW DID THIS ACCIDENT OCCUR? (Please describe fully the events that resulted in inury or occupational disease. SOURCE OF INJURY EVENT Tell what happened. Please use separate sheet if necessary) TIME WORKSHIFT BEGAN AM PM WHAT WAS EMPLOYEE DOING WHEN INJURED? (Please be specific. Identify tools, equipment or material the employee was using) TASK ACTIVITY ACCIDENT FACTOR AOS OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEEE (e.g. the machine employee struck against or struck him; the vapor or poison inhaled or swallowed; the chemical that irritated his skin. In cases of strains, the thing he was lifting, pulling, etc.) DESCRIBE IN DETAIL THE NATURE OF THE INJURY, ILLNESS AND PART OF THE BODY AFFECTED DISFIGUREMENT BURNS YES NO NATURE OF INJURY PART OF BODY TIME LOST INFORMATION DATE DISABILITY BEGAN WAS EMPLOYEE FURNISHED AVG WKLY WAGE IF EMPLOYEE IS BACK TO WAS EMPLOYEE PAID IN IF EMPLOYEE DIED GIVE DATE HOURLY WAGE MONTHLY SALARY HRS WKED/WK WEIGHING MEALS OR LODGING WORK GIVE DATE FULL FOR DAY OF INJURY FACTOR ILLNESS YES NO YES NO treatment OBTAIN NAME OF TREATING PHYSICIAN FROM EMPLOYEE GIVE NAME AND ADDRESS OF SURVIVORS ON BACK NAME OF PHYSICIAN ADDRESS PHYSICIANS ID CODE NAME OF MEDICAL FACILITY ADDRESS YES NO INPATIENT OVERNIGHT? EMERGENCY ROOM ONLY? INSURANCE CARRIER I.D. NAME OF WC INSURANCE CARRIER NAME OF ADJUSTING COMPANY IF LIABILITY DENIED WHY? IS LIABILITY DENIED? YES NO POLICY NO. POLICY RECORD ADJUSTER NAME CARRIER CASE NO. ADJUSTER I.D. MEDICAL DEDUCTIBLE TITLE DATE (REV. NOV/01) MM / DD / YY

2 STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building, 830 Punchbowl Street, Room 209, 209, Honolulu, Hawaii INSTRUCTION SHEET FOR FORM WC-5 Instructions IMPORTANT: If If information provided is is incomplete, this this claim will not be processed and and will will be be returned to to the the employee. Please Please complete the the form form in in triplicate. Please distribute the the form form as as follows: original and and one one copy copy to the to the appropriate District District Office Office (see (see next next page) page) and and one one copy copy for for employee s records. records. Ensure information indicated is is CLEAR, LEGIBLE, COMPLETE AND ACCURATE. INJURED PERSON: Name: Enter full, complete name shown on on injured person s social social security security identification card card (no (no nicknames). : : Enter mailing address. EMPLOYER: Name: Enter the the complete business name name of the of the employer. : Enter full full address of of employer including city, city, state state and and zip zip code. code. INSURANCE CARRIER: Name: Enter the the name name of of the the insurance company that that handles handles workers workers compensation for the for employer. the employer. INJURY: Date Date of of Accident: Enter specific date date injury injury occurred. Time: Specify time time and and include a.m. a.m. or or p.m. p.m. Describe Injury/Illness: How and and where did did the the accident occurred? Reason for for Filing: Specify reason(s) for for filing filing this this claim. WITNESS: Enter Enter name name and and address address of someone of someone who who saw saw accident, accident, if any. if any. NOTICE: Indicate whether whether you you notified notified your your employer of of the the injury. injury. ATTENDING PHYSICIAN: Enter Enter name name and and address address of the of the physician physician who who treated treated you you for this for this injury injury and and attach attach available available medical medical reports reports to this to claim. this claim. REPRESENTED BY: You You may may leave leave this this part part blank, blank, but but if you if you are are represented, represented, enter enter the the name name and and address address of attorney/union of attorney/union agent, agent, or other or other : : Enter Enter full full address address of of your your representative representative to include to include city, city, state state and and zip zip code. code. OF OF CLAIMANT: CLAIMANT: Sign your name and date. Sign your name and date. Visit Visit our Website at for for ALL ALL interactive interactive and downloadable and downloadable forms. forms.

3 INSTRUCTION SHEET FOR FORM WC-5 Page 2 of 2 The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly. Please remember to sign and date the form before submitting it. Delivery Information Delivery by U.S. Mail, In-Person, or via Fax Department of Labor and Industrial Relations, Disability Compensation Division Oahu Princess Keelikolani Building 830 Punchbowl Street, Room 209 Honolulu, Hawaii Mailing : P.O. Box 3769 Honolulu, Hawaii Phone: (808) Fax: (808) Hawaii 75 Aupuni Street, Room 108 Hilo, Hawaii Phone: (808) Fax: (808) Kauai 3060 Eiwa Street, Room 202 Lihue, Hawaii Phone: (808) Fax: (808) West Hawaii Ashikawa Building Halekii Street, Room 2087 Kealakekua, Hawaii If Mailing, Please Mail to This : P.O. Box 49, Kealakelua, Hawaii Phone: (808) Fax: (808) Maui 2264 Aupuni Street, #2 Wailuku, Hawaii Phone: (808) Fax: (808) Visit our Website at for ALL interactive and downloadable forms.

4 STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building, 830 Punchbowl Street, Room 209, 209, Honolulu, Hawaii INSTRUCTION FORM SHEET WC-5 FOR FORM WC-5 Injured Person Name Instructions IMPORTANT: If information provided is incomplete, this claim will not be processed and will be returned to the employee. Please complete the form in triplicate. Please distribute the form as follows: original and one copy to the appropriate District Office Occupation (see next page) and one copy for employee s records. Telephone Ensure information indicated is CLEAR, LEGIBLE, COMPLETE Social AND Security ACCURATE. No. ( ) INJURED PERSON: Employer Name: Enter full, complete name shown on injured person s social security identification card (no nicknames). : Name Enter mailing address. EMPLOYER: Name: Enter the complete business name of the employer. Nature : of Business Enter full address of employer including city, state and Telephone zip code. No. ( ) INSURANCE CARRIER: Insurance Name: Enter Carrier the name of the insurance company that handles workers compensation for the employer. Name INJURY: Date of Accident: Enter specific date injury occurred. Time: Specify time and include a.m. or p.m. Describe Injury/Illness: How and where did the accident occurred? Injury Reason for Filing: Specify reason(s) for filing this claim. Date WITNESS: of Accident Time of Injury Date Disability Began a.m. p.m. Enter name and address of someone who saw accident, if any. If not on employer s premises, indicate place where accident occurred NOTICE: Indicate whether you notified your employer of the injury. Describe how accident occurred ATTENDING PHYSICIAN: Enter name and address of the physician who treated you for this injury and attach available medical reports to this claim. Describe REPRESENTED injury/illnessby: You may leave this part blank, but if you are represented, enter the name and address of attorney/union agent, or other Reason : for filing: Enter full address of your representative to include city, state and zip code. Employer has not filed WC-1 Reopening of old claim Insurance carrier has not paid benefits OF CLAIMANT: Sign Others your (explain) name and date. Visit Visit our Website at for for ALL ALL interactive interactive and downloadable and downloadable forms. forms.

5 FORM WC-5 Page 2 of 2 Witness Notice Did you notify the employer of the injury? Yes No If so, when: How: Oral Written To whom: Attending Physician 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 individual. I hereby authorize any physician and/or hospital to release any information related to any treatment rendered to me. Represented by ATTORNEY/UNION AGENT OF CLAIMANT Auxiliary aids and services are available upon request. Please call: (808) ; TTY (808) ; and for neighbor islands, TTY 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. Visit our Website at for ALL interactive and downloadable forms.