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Get HI WC-1 2016-2024

to report promptly is a misdemeanor punishable by not more than a $5,000 fine. (Sec 386-95, H.R.S. NOTIFY THE DIVISION IMMEDIATELY IF INJURY RESULTS IN DEATH.) EVERY QUESTION MUST BE ANSWERED FULLY TO AVOID FURTHER CORRESPONDENCE. EMPLOYEE NAME – LAST FIRST M.I. SOC SEC NO / DD / ADDITIONAL ADDRESS INFORMATION (C/O) OCCUPATION DATE HIRED MM / DD / RESET DATE OF BIRTH MM ADDRESS PHONE CASE NUMBER WC-1 EMPLOYER’S REPORT OF INDUSTRIAL INJURY NOTE: DO NOT WRITE IN SHADED BLO.

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