State 2021 Form HC-5 Employee Notification to Employer Available Online

The State of Hawaii 2021 Form HC-5 Employee Notification to Employer is now available for download from the Department of Labor and Industrial Relations (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

The signed form is applicable only within the calendar year 2021, and must be kept on file for 2 years.

The form may be downloaded from the DLIR site