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Get HI WC-1 2003

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. The law requires the employer to furnish the injured employee a copy of this report. CASE NUMBER W C -1 E M P L O Y E R ’ S R E P O R T O F I N D U S T R I AL I N J U R Y NOTE: DO NOT WRITE IN SHADED BLOCKS IDENTIFICATION SECTION EMPLOYEE NAME - LAST M.I. FIRS.

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