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Hawaii Report of Injury by Employee to Employer to be Filed with Worker's Compensation Agency of State

Category:
Workers Compensation - Injury Reports
State:
Multi-State
Control #:
US-01494BG
Format:
Word; 
Rich Text
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Description

Workers' compensation laws are designed to ensure payment by employers for
some part of the cost of injuries, or in some cases of occupational diseases, received by employees in the course of their work. Worker's compensation legislation requires the employer to furnish a reasonably safe place to work, suitable equipment, rules and instructions. State workers' compensation statutes vary by state. The Federal Employment Compensation Act covers non-military federal employees or those workers employed in some significant aspect of interstate commerce.


The compensation acts require that notice of the fact of injury be given to the employer, or to the compensation board or commission, or to the insurance carrier, or to all of them. This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.

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FAQ

If you have already reported your injury to your employer or supervisor, and your employer has not filed a claim, you may file a Form WC-5, ?Employee's Claim for Workers' Compensation Benefits? with this Division or on the neighbor-island, the Department of Labor and Industrial Relations District Office nearest you.

WC-5 Employee's Claim for Workers' Compensation.

Any employer, other than those excluded (section 386-1), having one or more employees, full-time or part-time, permanent or temporary, is required to provide WC coverage for its employees.

The 2023 Maximum Weekly Benefit Amount for TDI is $765.00. For more information on TDI in Hawaii, employers may visit the DLIR Disability Compensation Division's webpages: About Temporary Disability Insurance and related Frequently Asked Questions. The 2023 Maximum Weekly Benefit Amount for WC is $1,090.00.

Notify the employer immediately of the disability. Ask for Form TDI-45, Claim for TDI Benefits, from the employer. A TDI claim must be filed within 90 days of the start of the disability period. Complete Part A, Claimant's Statement, of the claim form.

How do I file a TDI claim? Notify your employer immediately of your disability. Ask for Form TDI-45, Claim for TDI Benefits, from your employer. ... Complete Part A, Claimant's Statement, of the claim form. Take the form to your physician to certify your disability on Part C, Doctor's Statement.

Maximum Weekly Benefit (58% of the Maximum Weekly Wage Base) $765 $697 Claim Eligibility Requirement To be eligible for TDI benefits, an employee must have at least 14 weeks of Hawaii employment during each of which the employee was paid for 20 hours or more and earned not less than $400 in the 52 weeks preceding the ...

In order for an employee to be eligible for TDI benefits, an employee must have at least 14 weeks of Hawaii employment during which the employee was paid 20 hours or more and earned not less than $400 in the 52 weeks preceding the first day of disability. The 14 weeks need not be consecutive nor with only employer.

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