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WORKERS' COMPENSATION 1 FORM


Dear Employer:

     The WC1 form should be used to to report every work injury to an employee causing absence for one day or more or which requires medical services other than first aid treatment. This should be completed within 7 working days after knowledge of the injury. (Sec. 386-95. Hawaii Revised Statutes).

For Your Info: Failure to report promptly is a misdemeanor punishable by not more than a $5,000 fine.

Use the "TAB" key to move from the sections you are required to complete. Enter numbers without "spaces".

Type the name of the management contact person at the bottom of the WC1 from.

Please PRINT and/or save a copy for your records and either fax or email the completed WC1 to me.

MAIL THE ORIGINAL WC1 TO:
BUSINESS INSURANCE SERVICES INC,
615 PI'IKOI STREET, #1901
HONOLULU, HI 96814

Do not hesitate to call if you need any assistance regarding the completion of this form or on any claim.

Lee Fujita
Claims Manager
Business Insurance Services Inc.
Email: lfujita@bisihi.com
Efax: 808 628-6927
Phone: 808 592-5029

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Click Here for WC1 Form










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