Form Instructions

Workers’ Compensation Questionnaire Form

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 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