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