Form Hc-4 Health Care Coverage Questionnaire
Download a blank fillable Form Hc-4 Health Care Coverage Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Hc-4 Health Care Coverage Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
INSTRUCTION SHEET FOR FORM HC-4
HEALTH CARE COVERAGE QUESTIONNAIRE
Instructions
Please completely fill out the HC-4 HEALTH CARE COVERAGE QUESTIONNAIRE FORM.
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
Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813
Visit our Website at for ALL interactive and downloadable forms.
(Rev. 10/05)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal