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Claim Forms

Here are forms for employers to use to file and manage claims. If you have questions about a form, our Claims Department can assist you. Call us at 208-8210.
Employee’s Report of Injury
WC-1 Form – Employer’s Report of Industrial Injury (PDF)
WC-1 Instructions – Employer’s Report of Industrial Injury (PDF)
WC-14 – Employee’s Wage Report for 52 Weeks Prior to Date of Injury (PDF)
WC-1 for CBWC Program – Employer’s Report of Industrial Injury for Collectively Bargained Workers’ Comp Program (PDF)
Return to Work Agreement – Modified/Light Duty (PDF)
Medical Certificate Report
Hawai`i Workers’ Compensation Law Highlights (PDF)
Job Analysis Form for Employers

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