Get Hi Hc-61 2005-2025

The HI HC-61 form, officially known as the Health Care Application for Self-Insurance Authorization, is essential for employers seeking permission to operate as self-insurers in Hawaii. This guide provides a clear and comprehensive walkthrough for filling out the form online, ensuring you have the necessary information at hand for a smooth application process.

Follow the steps to successfully complete the HI HC-61 form online.

1. Click ‘Get Form’ button to obtain the HI HC-61 form and open it in your preferred PDF editor.
2. Begin by entering the name of the applicant exactly as registered with the Department of Labor and Industrial Relations (DLIR). Include the Department of Labor number, if applicable.
3. Provide the mailing address in Hawaii, choosing the appropriate type of business: Corporation, Sole Proprietorship, Partnership, or Other, if necessary. Additionally, fill in the street address and phone number.
4. List any other business locations in Hawaii, if applicable.
5. Detail the nature of your business as well as the number of employees in Hawaii to be covered under the health care plan, along with the total number of employees, including those from parent and subsidiary companies.
6. If your business is a subsidiary company, fill in the name and address of the parent company and its percentage of stock ownership.
7. Indicate if your business operates under any name other than that registered. If yes, provide the alternative name, address, and nature of the business.
8. State the date your business commenced operations in Hawaii.
9. Enter the net profit or loss figures after taxes for the last five years.
10. Provide the details of the individual responsible for submitting audited financial statements annually, including their name, title, address, telephone number, and fax number.
11. List the current health care contractors engaged by the applicant.
12. Answer whether any health care insurance application has been rejected or if any policy has been canceled. If yes, provide the relevant dates, the name of the contractor, and the reason.
13. Identify the individual in your organization who will oversee the self-insurance program, including their name, title, address, and contact details.
14. Specify how claims administration will be handled: by your own organization or an outside organization. Provide the names and contact details of all administrators.
15. Indicate whether claims administration will occur at more than one location and provide necessary information if applicable.
16. Confirm if the health care self-insurance program will be supplemented by an insurance policy. If yes, attach a copy of the policy.
17. State whether there is any pending litigation that may affect the applicant's financial condition.
18. Ensure all required attachments are included: current independent auditor’s report, audited financial statements, corporate resolutions (if applicable), health care plan, and any supplemental insurance policies.
19. Sign and date the application, ensuring all information is accurate and complete before submission.
20. Once all sections are filled, save your changes, then download, print, or share the completed form as needed.

Begin filling out the HI HC-61 form online today for a seamless self-insurance application process.