Form Hc 6 PDF Details

Form HC 6 is a request for proposal (RFP) that can be used by businesses when they are looking to outsource a project or service. The form can be used to solicit bids from potential vendors, and it can also be used to compare proposals from different vendors once bids have been received. The form is divided into five sections, which allow businesses to describe the project or service they need, provide information about the vendor selection process, ask for pricing information, and more. Form HC 6 is a useful tool for businesses that want to make sure they get the best deal possible when outsourcing a project or service.

QuestionAnswer
Form NameForm Hc 6
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesDCD HC 6_herman hc 6 form

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STATE OF HAWAII

DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

DISABILITY COMPENSATION DIVISION

830 Punchbowl Street, Princess Keelikolani Building, Room 209, Honolulu, Hawaii 96813

INSTRUCTION SHEET FOR FORM HC-6

EMPLOYER'S REQUEST FOR PREMIUM SUPPLEMENTATION

Instructions

ATTENTION: SMALL EMPLOYERS (THOSE WITH LESS THAN 8 REGULAR EMPLOYEES) SUBJECT TO HAWAII’S PREPAID HEALTH CARE (PHC) ACT, CHAPTER 393*, HAWAII REVISED STATUTES (HRS)

A special fund for health care premium supplementation is available to employers who meet the criteria established under Section 393-45, HRS. A claim for premium supplementation must be filed with the Department of Labor and Industrial Relations within two years after the end of the employer’s taxable year.

Section 393-45 of the PHC Act specifies that an employer is entitled to premium supplementation if the employer satisfies all of the following qualifying conditions:

1.Employer employs less than eight employees entitled to PHC coverage.

2.The employer’s health care plan is approved under Section 393-7(a) of the PHC Act.

3.Employer’s share of the premium cost for eligible employees (single coverage only) exceeds 1.5% of the total wages payable to such employees and the amount of such excess is greater than 5% of the employer’s income before taxes directly attributable to the business.

4.The fund will not supplement employee’s share of the premium, dependent’s coverage and the additional premium cost for the more expensive plan should the employer have more than one plan.

If you meet the above criteria, please contact the Disability Compensation Division at (808) 586-9199 and request a copy of Form HC-6, Employer’s Request for Premium Supplementation.

Please complete Form HC-6 and return it with the following documents:

1.Individual payroll records

2.Copy of the State of Hawaii income tax return for the business certified by the Department of Taxation

3.Copy of the U.S. income tax return for the business

4.Quarterly payroll tax reports (Forms UC-B6 and 941)

5.Form W-2, wage and tax statement

6.Health care contractor’s monthly medical billing statements

7.Any other related documents pertaining to the request for PHC premium supplementation

8.Temporary disability insurance premium statements

*Please visit www.hawaii.gov/labor for a complete text of Chapter 393, HRS, where you can find the sections that are referenced above.

The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly.

Please remember to sign and date the form before submitting it.

Delivery Information

Delivery by U.S. Mail

Department of Labor and Industrial Relations, Disability Compensation Division

P.O. Box 3769, Honolulu, Hawaii 96812-3769

Delivery In-Person

Department of Labor and Industrial Relations, Disability Compensation Division

830 Punchbowl Street, Princess Keelikolani Building, Room 209, Honolulu, Hawaii 96813

Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.

(Rev. 10/05)

STATE OF HAWAII

DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

DISABILITY COMPENSATION DIVISION

830 Punchbowl Street, Princess Keelikolani Building, Room 209, Honolulu, Hawaii 96813

FORM HC-6 EMPLOYER'S REQUEST FOR PREMIUM SUPPLEMENTATION

Employer Name

Address

DOL Account No.

 

Federal I.D. No./Social Security No.

-

-

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Contractor Name

Plan Name

 

 

 

 

Total Number of Employees Eligible for PHC Coverage

Total annual wages paid to employees eligible

$

 

for and covered under employer’s PHC plan

 

 

 

 

 

To Calculate Premium Supplementation:

A.Total annual premium cost for providing single PHC

 

coverage to eligible employees (per billing statements from

$

 

 

 

 

 

 

 

 

health care contractor)

 

 

 

 

 

 

 

 

B.

Employees’ share of premium cost (1.5% of employee’s

$

 

 

 

 

 

 

 

 

wages not to exceed 50% of premium cost)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Employer’s share of the premium cost (A minus B)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

1.5% of total wages paid to covered eligible employees

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E.

Difference (Note: Stop here if E is not a positive number. You

$

 

 

 

 

 

 

 

 

are not entitled to premium supplementation.) (C minus D)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F.

5% of employer’s adjusted income before taxes directly

$

 

 

 

 

 

 

 

 

attributable to the business (Leave blank if not known.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G.

This is an approximate amount of premium supplementation

 

 

 

 

 

 

 

 

 

claimed (If G is a positive number, you may be entitled to

$

 

 

 

 

 

 

 

 

premium supplementation.) (E minus F)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Period for which premium supplementation is covered

Mo /

Day /

 

to

Mo /

Day /

 

(taxable year)

 

 

Year

 

Year

 

Attached with my application are individual payroll records, U.S. income tax return for the business, certified copy of State of Hawaii income tax return, quarterly payroll tax reports (Forms UC-B6 and 941), Form W-2, wage and tax statement, health care contractor’s monthly medical billing statements, temporary disability insurance premium statements, and all related documents pertaining to my request for PHC premium supplementation.

I certify that the information submitted above is true and correct to the best of my knowledge. I understand that the Department of Labor and Industrial Relations, Disability Compensation Division, reserves the right to audit company records in considering our request.

Authorized Signature

Print Name and Title

Telephone No.

()

Date

Fax No.

()

Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.

(Rev. 10/05)

FORM HC-6 EMPLOYER'S REQUEST FOR PREMIUM SUPPLEMENTATION

Page 2 of 2

FOR OFFICE USE ONLY

Approved

Amount

$

Period

Mo / Day / Year

to

Mo / Day / Year

Disapproved because

Audited by

Approved by

Date

Date

Auxiliary aids and services are available upon request. Please call: (808) 586-9199; TTY (808) 586-8847; and for neighbor islands, TTY 1-888-569-6859. A request for reasonable accommodation(s) should be made no later than ten working days prior to the needed accommodation(s).

It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex, marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation, and National Guard participation, be subjected to discrimination, excluded from participation in, or denied the benefits of the Department’s services, programs, activities, or employment.

Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.

(Rev. 10/05)

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Step 1: Press the "Get Form" button at the top of this webpage to access our editor.

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It will be an easy task to fill out the pdf adhering to our detailed tutorial! Here is what you have to do:

1. When completing the Form Hc 6, make sure to include all needed blank fields in its associated area. It will help expedite the work, enabling your details to be processed swiftly and correctly.

Find out how to complete Form Hc 6 portion 1

2. Right after the previous part is completed, go on to enter the suitable information in these - Employer Name Address, DOL Account No, Federal ID NoSocial Security No, State, Zip Code, City, Health Care Contractor Name, Plan Name, Total Number of Employees Eligible, Total annual wages paid to, To Calculate Premium, coverage to eligible employees per, wages not to exceed of premium, C Employers share of the premium, and D of total wages paid to covered.

The right way to prepare Form Hc 6 step 2

Be very careful while filling out Total Number of Employees Eligible and DOL Account No, as this is the part in which many people make some mistakes.

3. In this particular stage, have a look at Period for which premium, Mo Day Year, Mo Day Year, taxable year, Attached with my application are, Authorized Signature, Print Name and Title, Date, Telephone No, Fax No, Visit our Website at, and Rev. All of these are required to be filled out with greatest accuracy.

Form Hc 6 conclusion process explained (part 3)

4. This paragraph arrives with all of the following fields to type in your details in: FORM HC EMPLOYERS REQUEST FOR, Approved, Amount, Disapproved because, Audited by, Approved by, FOR OFFICE USE ONLY, Period, Mo Day Year, Mo Day Year, Date, and Date.

Form Hc 6 conclusion process clarified (portion 4)

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