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Update on HMSA operations related to Iselle. Learn more.

Workers’ Compensation Questionnaire Form

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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