DescriptionPlease remember to sign and date the Form before submitting it to your employer. Rev.08/12 FORM HC-5 EMPLOYEE NOTIFICATION TO EMPLOYER Employer Information Employer Name Address DOL Account No. Telephone No. In accordance with the provisions of the Hawaii Prepaid Health Care Act Chapter 393 Hawaii Revised Statutes this is to notify you that Check appropriate box es 1. STATE OF HAWAII DEPARTMENT OF LABOR AND ...
Form was Filled by