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WC5A rev. 01/2022 CASE NUMBER STATE OF HAWAII DEPARTMENT OF LABOR & INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION AMENDDECEDENTS INFORMATION SECTION 1 FIRSTCLAIMANT NAME LASTIDENTIFICATION

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How to fill out wc-5a dependents claim for

01

Obtain a copy of the wc-5a dependents claim form.

02

Fill out the claimant information section including name, address, and contact details.

03

Provide information about the deceased worker including their name, date of birth, and date of death.

04

List all dependents of the deceased worker including their relationship to the deceased and their age.

05

Sign and date the form before submitting it to the appropriate authority.

Who needs wc-5a dependents claim for?

01

Family members or dependents of a deceased worker who are seeking compensation benefits.

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What is wc-5a dependents claim for?

The wc-5a dependents claim is for individuals who are claiming benefits as dependents of a deceased worker.

Who is required to file wc-5a dependents claim for?

Dependents of a deceased worker who wish to claim benefits are required to file the wc-5a dependents claim.

How to fill out wc-5a dependents claim for?

To fill out the wc-5a dependents claim, the dependent must provide information about their relationship to the deceased worker and any other relevant details requested on the form.

What is the purpose of wc-5a dependents claim for?

The purpose of the wc-5a dependents claim is to allow dependents of a deceased worker to claim benefits under workers' compensation.

What information must be reported on wc-5a dependents claim for?

The wc-5a dependents claim must include information such as the dependent's relationship to the deceased worker, any other sources of financial support, and any other relevant details requested on the form.

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