Do not use this form if you work for only 1 employer and that employer provides you with health care coverage or you work less than 20 hours per week for your employer.
Also use it if: the employee terminates an exemption or changes principal and/or secondary employer designation.
Principal employer: the principal employer is the employer who pays the employee the most wages.
Calendar year: the employee's selection below is applicable only within calendar year 2025.
Renewing: if the employee will be renewing the selection after 2025, have the employee complete the form for the appropriate year.
Employer: keep this completed, signed form on file for 2 years. Give a copy of this completed form to the employee.
Return it: return completed form to employer.
| Question | Answer |
|---|---|
| Form Name | Form HC-5 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 13 |
| Avg. time to fill out | 3 min |
| Edition | 03/2025 |
| Issuing agency | Department of Labor and Industrial Relations, Disability Compensation Division |
| Where to return it | The employer |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | HC-5, HC5, HC 5, Form HC-5, Hawaii HC-5, Employee Notification to Employer |
| Official source | Form HC-5 (Rev 03/2025), Hawaii Department of Labor and Industrial Relations |