2020 Form HC-5 Available for Use

The State of Hawaii Department of Labor and Industrial Relations (DLIR) Form HC-5 (Employee Notification to Employer for Calendar Year 2020)(Rev. 09/19) is now accessible on the DLIR website. 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

Employees who elect to waive an employer’s health insurance coverage must sign this form annually.