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Hawaii form insurance 2026
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- Click ‘Get Form’ to open the HC-61 Health Care Application for Self-Insurance Authorization in the editor.
- Begin by entering the name of the applicant exactly as registered with the Department of Labor and Industrial Relations. Include your DOL number.
- Fill in your mailing address in Hawaii, and select your business type (Corporation, Sole Proprietorship, Partnership, or Other). If applicable, provide a different street address.
- Provide your contact information including telephone and fax numbers. Then, detail other business locations in Hawaii if necessary.
- Indicate the nature of your business and the number of employees covered under the health care plan. Also, include total employee numbers from parent and subsidiary companies.
- If applicable, provide details about any subsidiary company including its name, address, and percentage of stock ownership.
- Complete sections regarding any alternative business names, financial history over the last five years, and responsible individuals for submitting financial statements.
- Ensure all required attachments are included before signing and dating the form. Choose a delivery method from U.S. Mail or In-Person submission options provided at the end of the form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2005 | 4.8 Satisfied (142 Votes) |
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