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Get HI HC-5 2013

Instructions 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. UPON REQUEST ONLY, submit a copy of this form to the State Department of Labor & Industrial Relations. (Form must be renewed every December 31.) 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 acc.

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