HMSA’s Third-Party Liability Injury/Illness Report Form

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Please print and fill out this form to report a third-party liability injury or illness. Mail it to HMSA at the address below.

To avoid delays, please make sure your information is complete.

Section I. Fill in the following:

  1. Name of the HMSA member or dependent injured or ill.
  2. Date of injury or illness.
  3. Location of where the injury or illness occurred.
  4. How the accident happened.
  5. Description of the injury or illness.
  6. Your work and home phone numbers.
  7. Whether you hired or plan to hire an attorney. If you answered “yes,” indicate the attorney’s name, address and phone number.

Section II. Check “yes” or “no” to answer if your accident was work-related. If you check “yes,” complete the rest of the section. Fill in the following:

  1. Whether or not you filed for workers’ compensation. If you answer “no,” explain the reason.
  2. The status of your workers’ compensation claim.
  3. The name and phone number of your employer and the insurance company covering your workers’ compensation.

Please also complete the Workers’ Compensation Questionnaire. Submit a copy of the settlement document if your case has been settled.

Section III. Check “yes” or “no” to answer if your injury involved a motor vehicle. If you check “yes,” complete the rest of the section. Fill in the following:

  1. If you were a passenger, driver or pedestrian.
  2. The vehicle owner’s name, address, phone number, and motor vehicle insurance carrier (if you were the driver or a passenger).
  3. The name, address, phone number, and motor vehicle insurance of the owner of the vehicle that struck you.
  4. If no-fault benefits are available. If you check “yes,” indicate the policy limit in dollars. If you check “no,” explain the reason.
  5. The name of your motor vehicle insurance carrier. If you don’t have a carrier, name the motor vehicle insurance carrier of anyone in your household.

Section IV. Check “yes” or “no” to answer if another person(s) may be responsible for your accident or illness. If you check “yes,” complete the rest of the section. Fill in the following:

  1. The name and address of the person(s) you believe could be responsible.
  2. Date on which you discovered the name of the responsible party.
  3. Whether you made a written claim or initiated any legal action.
  4. The status of your claim. Include information related to the complaint with this form.
  5. If you received any money resulting from your accident.
  6. The date and amount of the settlement and person whom you received it from. Include a copy of the settlement with this form.
  7. If you won’t be pursuing a third-party claim, explain why.

Print and sign your name. Include the date when you filled out the form and your HMSA number (located on your HMSA card).

Mail this form to:
HMSA/8-CA/Other Party Liability
P.O. Box 860
Honolulu, HI 96808