HC-5 (Rev.09/23) Use this form if the employee works at least 20 hours per week and: •Works for 2 or more employers** or •Claims an exemption or waiver from health care coverage or

HC-5 (Rev.03/2025) STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION . Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 . FORM HC-5 EMPLOYEE NOTIFICATION TO EMPLOYER FOR CALENDAR YEAR . 2025. Use this form if the employee works at least 20 hours per week and:

Oct 29, 2024 · Eligible employees may waive mandated coverage by completing the Form HC-5 (Employee Notification to Employer) every calendar year, if certain situations apply, including: Being covered by a federally established health insurance (e.g., Medicare or Medicaid);

covered by a Federally established health insurance or prepaid health care plan, such as Medicare, Medicaid or medical care benefits provided for military dependents and military retirees and their dependents. covered as a dependent (e.g. spouse, child, etc.) under a qualified health care plan. (e.g. MedQuest).

Feb 6, 2017 · Hawaii employers who are subject to the Prepaid Health Care Act should be familiar with Form HC-5, which covers employee waivers for health care coverage. What do you do when an employee checks Box #4?

Oct 19, 2021 · Employers must ensure employees who choose to waive health care coverage under Hawaii's Prepaid Health Care Act, complete Form HC-5 annually. Companies with employees who waived coverage in 2021 should follow up with these employees.

HC-5 (Rev.09/22) Use this form if the employee works at least 20 hours per week and: •Works for 2 or more employers** or •Claims an exemption or waiver from health care coverage or •Terminates an exemption or •Changes principal and/or secondary employer designation** THIS SECTION IS FOR THE EMPLOYER TO COMPLETE.

A group for those that might have been or are associated with the Navy helicopter Squadron, HC-5. Current & former members of HSC-25 are welcome, too. If I can't verify your affiliation with HC-5 through your profile, please message one of the admins.

HC-15 This form can only be completed by PHC plan contractors. Contact your PHC plan contractor for information. HC-61 Application for Self-Insurance Authorization

To claim an exemption or individual waiver, an employee must complete and submit “Employee Notification to Employer” (Form HC-5) to the employer. The employer retains the original and gives a copy to the employee.