WC-3 rev.

01/2022
CASE NUMBER
STATE OF HAWAII
DEPARTMENT OF LABOR & INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
DATE RECEIVED
NEW WC-3 CARRIER'S CASE REPORT
AMEND NOTE: COMPLETE THE FILLABLE-DARK SHADED BLOCKS

CLAIMANT – SECTION 1
CLAIMANT NAME – LAST FIRST M.I. SUFFIX

IDENTIFICATION TYPE IDENTIFICATION NUMBER DATE OF INJURY/ILLNESS

SSN PASSPORT
ADDRESS CITY STATE ZIP CODE

EMAIL ADDRESS PHONE NUMBER

( ) -
EMPLOYER – SECTION 2
REGISTERED EMPLOYER DBA

ADDRESS CITY STATE ZIP CODE

EMPLOYER POINT OF CONTACT PHONE NUMBER EMAIL ADDRESS

( ) -
INSURANCE CARRIER – SECTION 3
NAME OF WC INSURANCE CARRIER CARRIER ID CARRIER CASE NUMBER

POLICY NUMBER POLICY PERIOD MEDICAL DEDUCTIBLE

FROM: TO:
ADJUSTER NAME EMAIL ADDRESS PHONE NUMBER ADJUSTER ID NUMBER

( ) -
ADDRESS CITY STATE ZIP CODE

CHECK ONE: ADDITIONAL INFORMATION

1. DATE OF FIRST INCOME REPLACEMENT PAYMENT

2. REOPEN CASE
3. FINAL PAYMENT TO PREVIOUSLY ENDED CASE FOR

4. YEAR END REPORT - Complete the Benefit Payment Table

FINAL REPORT - Complete the Benefit Payment Table

5.
(**COPY OF REPORT TO EMPLOYEE)
RETURN TO WORK DATE WEEKLY COMPENSATION RATE
BENEFIT ADJUSTMENT? NO YES BENEFIT REIMBURSEMENT? NO YES

CARRIER’S COMMENTS

Page 1 of 4

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

Auxiliary aids and services are available upon request to individuals with disabilities.
TDD/TTY Dial 711 then ask for (808) 586-9161.
 WC-3 rev. 01/2022
CASE NUMBER

BENEFIT PAYMENT TABLE – SECTION 4

BENEFIT PAYMENTS NOT PREVIOUSLY TOTAL PAYMENTS MADE TO

# DAYS DATE RANGE PRIOR PAYMENTS ($)
PAYMENTS REPORTED ($) DATE ($)

TEMPORARY TOTAL DISABILITY (TTD)

1 TTD PERIOD 1 FROM: TO:

2 TTD PERIOD 2 FROM: TO:

3 TTD PERIOD 3 FROM: TO:

4 TTD PERIOD 4 FROM: TO:

5 TTD PERIOD 5 FROM: TO:

6 TTD PERIOD 6 FROM: TO:

7 TTD PERIOD 7 FROM: TO:

8 TTD PERIOD 8 FROM: TO:

9 TTD PERIOD 9 FROM: TO:

10 TTD PERIOD 10 FROM: TO:

11 TTD PERIOD 11 FROM: TO:

12 TTD PERIOD 12 FROM: TO:

TOTAL TTD

TEMPORARY PARTIAL DISABILITY (TPD)

1 TPD PERIOD 1 FROM: TO:

2 TPD PERIOD 2 FROM: TO:

3 TPD PERIOD 3 FROM: TO:

4 TPD PERIOD 4 FROM: TO:

5 TPD PERIOD 5 FROM: TO:

TOTAL TPD

PERMANENT TOTAL DISABILITY (PTD)

1 PTD PERIOD 1 FROM: TO:

2 PTD PERIOD 2 FROM: TO:

3 PTD PERIOD 3 FROM: TO:

4 PTD PERIOD 4 FROM: TO:

5 PTD PERIOD 5 FROM: TO:

TOTAL PTD

Page 2 of 4

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

Auxiliary aids and services are available upon request to individuals with disabilities.
TDD/TTY Dial 711 then ask for (808) 586-9161.
 WC-3 rev. 01/2022
CASE NUMBER

BENEFIT PAYMENT TABLE – SECTION 4 (continued)

BENEFIT PAYMENTS NOT PREVIOUSLY TOTAL PAYMENTS MADE TO

# DAYS DATE RANGE PRIOR PAYMENTS ($)
PAYMENTS REPORTED ($) DATE ($)

PERMANENT PARTIAL DISABILITY (PPD)

1 PPD PERIOD 1 FROM: TO:

2 PPD PERIOD 2 FROM: TO:

TOTAL PPD

DEATH

1 SPOUSE FROM: TO:

2 DEPENDENT FROM: TO:

3 DEPENDENT FROM: TO:

4 DEPENDENT FROM: TO:

5 DEPENDENT FROM: TO:

6 DEPENDENT FROM: TO:

7 DEPENDENT FROM: TO:

8 DEPENDENT FROM: TO:

9 BURIAL

10 FUNERAL

11 OTHER FROM: TO:

12 OTHER FROM: TO:

TOTAL DEATH

Page 3 of 4

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

Auxiliary aids and services are available upon request to individuals with disabilities.
TDD/TTY Dial 711 then ask for (808) 586-9161.
 WC-3 rev. 01/2022
CASE NUMBER

BENEFIT PAYMENT SUMMARY – SECTION 5

PAYMENTS NOT PREVIOUSLY TOTAL PAYMENTS MADE TO

BENEFIT PAYMENTS DAYS DATE RANGE PRIOR PAYMENTS ($)
REPORTED ($) DATE ($)

CARRYOVER AMOUNTS FOR TTD, TPD, PTD, PPD AND DEATH FROM PAGES 2 AND 3

TEMPORARY TOTAL
FROM: TO:
DISABILITY

TEMPORARY PARTIAL FROM: TO:

DISABILITY

PERMANENT TOTAL FROM: TO:

DISABILITY
PERMANENT PARTIAL
FROM: TO:
DISABILITY

DEATH FROM: TO:

CITY & COUNTY FROM: TO:

DISFIGUREMENT FROM: TO:

MEDICAL FROM: TO:

MATERIALS FROM: TO:

SERVICES OF FROM: TO:

ATTENDANT

REHABILITATION FROM: TO:

BENEFIT FROM: TO:

REIMBURSEMENT

BENEFIT FROM: TO:

ADJUSTMENT

OTHER FROM: TO:

OTHER FROM: TO:

GRAND TOTAL

SIGNATURE – SECTION 6

I hereby certify the accuracy of all the above statements.

PRINT NAME PHONE NUMBER EMAIL ADDRESS

( ) -
SIGNATURE DATE

NOTICE TO EMPLOYEE – SECTION 7

**The copy of this report constitutes notice that the final payment of compensation (as indicated hereon) on your
industrial injury/illness on the subject case will be closed. The determination shall not constitute a bar to your
reopening rights as provided by Section 386-89, HRS, nor to future medical benefits. For your protection, Hawaii law
requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable
by fines or imprisonment, or both.

Page 4 of 4

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

Auxiliary aids and services are available upon request to individuals with disabilities.
TDD/TTY Dial 711 then ask for (808) 586-9161.
 rev. 01/2022

ENGLISH This document contains important information. If you need language

assistance at no cost to you, please contact us by telephone or in person
immediately.

ILOKANO Daytoy nga dokumento ket addaan ti importante nga impormasyon. No

masapul mo ti mangipatarus nga libre, pangngaasim ta awagan na kami
ti telepono wenno umay na kami kitaen nga daras.

TAGALOG Ang dokumentong ito ay naglalaman ng importanteng impormasyon. Kung

nangangailangan kayo ng libreng tulong para maintindihan ito,
mangyaring makipag-ugnay sa amin sa pamamagitan ng telepono o
makipagkita kagaad sa amin.

CHINESE 此文件有重要信息。如果您需要免费的语言协助服务，请您立刻给我们打
SIMPLIFIED 电话或来我们办公室请求帮助。

CHINESE 此文件有重要信息。如果您需要免費的語言協助服務，請您立刻給我們打
TRADITIONAL 電話或來我們辦公室請求幫助。

SPANISH Este documento contiene información importante. Si necesita los servicios

de un intérprete sin costo alguno para usted, por favor llame de inmediato
por teléfono o contacte con alguna persona de nuestra oficina.

JAPANESE この書類には重要な情報が含まれています。無償で日本語の支援を受け
たい場合は、早急に電話あるいは直接窓口にて申込を行ってください。

CHUUKESE Mei auchea met masowan ei taropwe. Ika pwe ke mochen aninis ren
noumw chon chiaku esap kamo, kose mochen kokori kich won tengwa ika
fen pusin chuto rech.

MARSHALLESE Ilo pepa in ewor melele ko aorok. Ne kwoj aikuj jiban na ukok ilo ejjelok
wonen, jouj im kokkeitaak kem ilo talboon ak ilo wobij e ien eo emakaaj
tata.

KOREAN 이 문서는 중요한 정보가 포함되어 있습니다. 무료로 언어 도움이

필요하시면, 바로 전화 하시거나 오셔서 상담하십시오.

VIETNAMESE Tài liệu này bao gồm các thông tin quan trọng. Nếu bạn cần hỗ trợ ngôn
ngữ miễn phí, xin vui lòng đến gặp trực tiếp chúng tôi hoặc liên lạc qua
điện thoại ngay lập tức.

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

Auxiliary aids and services are available upon request to individuals with disabilities.
TDD/TTY Dial 711 then ask for (808) 586-9161.