Please print and fill out this form. Mail it to HMSA at the address below. To avoid delays, please make sure your information is complete. Also, complete the Third-Party Liability Injury/Illness Report Form.
- Fill in your name, HMSA subscriber number (located on your HMSA card), and work and home phone numbers.
- Indicate the date of the injury or illness.
- Briefly describe how the accident happened.
- Briefly describe your injury or illness.
- Indicate if you filed for workers’ compensation or not. If you haven’t filed, explain why.
- Fill in your employer’s name and telephone number.
- Check the statements that apply to you. Fill in additional information required for applicable statements and check the boxes as needed. Submit supporting documents.
- Sign and date the form.
Mail the completed questionnaire to:
8-CA/Other Party Liability
P.O. Box 860
Honolulu, HI 96808