Hawaii form insurance 2026

1. Click ‘Get Form’ to open the HC-61 Health Care Application for Self-Insurance Authorization in the editor.
2. Begin by entering the name of the applicant exactly as registered with the Department of Labor and Industrial Relations. Include your DOL number.
3. 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.
4. Provide your contact information including telephone and fax numbers. Then, detail other business locations in Hawaii if necessary.
5. 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.
6. If applicable, provide details about any subsidiary company including its name, address, and percentage of stock ownership.
7. Complete sections regarding any alternative business names, financial history over the last five years, and responsible individuals for submitting financial statements.
8. 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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