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STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, HawaiiINSTRUCTION SHEET FOR FORM WC-21
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Document Date: 2013-01-14 15:10:57

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File Size: 325,48 KB

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City

Honolulu / /

Company

Surety Bond Approved Securities / Parent Company Address (b) Parent Company / /

Currency

USD / /

Facility

Disability Compensation Division Princess Keelikolani Building / STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building / /

IndustryTerm

insurance policy / compensation insurance / proposed self-insurance plan / self-insurance program / /

Organization

Department of Labor / Self Insurer’s Own Organization / Claims administration / Own Organization / Industrial Relations / Disability Compensation Division / DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building / OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION / /

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Position

Director / Hawaii 96813 FORM WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION To / Director / Princess / Administrator / /

ProvinceOrState

Hawaii / /

URL

www.hawaii.gov/labor / /

SocialTag