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Get HI HC-5 2015-2024

Ons to employer: Provide coverage as required by 1 and 5 above. Keep the completed, signed form and give a copy to the employee. You must keep this form for 2 years. DO NOT SUBMIT this form to the State Department of Labor & Industrial Relations, unless it is requested. (Form must be renewed every December 31.) Auxiliary aids and services are available upon request. Please call: (808) 586-9188; TTY (808) 586-8847; TTY neighbor islands (888) 569-6859. A request for reasonable accommodation(s) sho.

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