STATE OF HAWAII 002DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS002 DISABILITY COMPENSATION DIVISION002 830 Punchbowl Street, Princess Keelikolani Building, Room 209, Honolulu, Hawaii 96813002 Mailing Address: P O Box 3769, Honolulu, Hawaii 96812-3769002 Telephone Number: (808) 586-9239002 INSTRUCTION SHEET FOR FORM HC-6 EMPLOYER'S REQUEST FOR PREMIUM SUPPLEMENTATION SMALL EMPLOYERS (THOSE WITH LESS THAN 8 ELIGIBLE S PREPAID HEALTH CARE (PHC) ACT, CHAPTER 393*, HAWAII REVISED STATUTES (HRS) A special fund for health care premium supplementation is available to employers who meet the criteria established under Section 393-45, HRS. Please Note: Due to federal funding restrictions, claims for premium supplementation will only be processed for health plan years beginning on or after January 1, 2017. Section 393-45(HRS) along with Sections 12-12-70 and 12-12-71 (Hawaii Administrative Rules) of the PHC Act specify002 that an employer is entitled to premium supplementation if the employer satisfies all of the following qualifying 002conditions: 0021. Employer employs less than eight employees entitled to PHC coverage. 2. E-7(a) of the PHC Act. 3. employees (single coverage only) exceeds 1.5% of the total before taxes directly attributable to the business. 4. Employer must be in business for profit and the request for supplementation must be filed within two years The fund will not supplement the share of the premium, coverage and the additional premium cost of the more expensive plan should the employer have more than one plan. Please complete Form HC-6, Request for Premium Supplementation, and return the form along with the following documents: 1. Individual payroll records and quarterly payroll tax reports (Forms UC-B6 and 941) 2. Copy of the State of Hawaii income tax return for the business certified by the Department of Taxation 3. Copy of the U.S. income tax return for the business 4. W-2 forms 5. statements and health plan rate exhibits 6. Additional records/documents may be requested when necessary *Please visit http://labor.hawaii.gov/dcd for forms, instructions, and a complete text of Chapter 393, HRS. Auxiliary aids and services are available upon request. Please call: (808) 587-8778; TTY (808) 586-8847; and for neighbor islands, TTY 1-888-569-6859. A request for reasonable accommodation(s) should be made no later than ten working days prior to the needed accommodation(s). It is the policy of the Department of Labor and Industrial Relations that no person shall, on the basis of race, color, sex, marital status, religion, creed, ethnic origin, national origin, age, disability, ancestry, arrest/court record, sexual orientation, and National Guard participation, be subjected to discrimination, excluded from participation in, or denied the benefits of (Rev. 12/17) American LegalNet, Inc. www.FormsWorkFlow.com 002DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS002 DISABILITY COMPENSATION DIVISION002 830 Punchbowl Street, Princess Keelikolani Building, Room 209, Honolulu, Hawaii 96813 Mailing Address: P O Box 3769, Honolulu, Hawaii 96812-3769 Telephone Number: (808) 586-9239 FORM HC-6 EMPLOYER'S REQUEST FOR PREMIUM SUPPLEMENTATION Employer Name DOL Account No. - - Federal I.D. No./Social Security No. Address City State Zip Code Health Care Contractor Name Plan Name / Plan Year (s) - MM/DD/YR , and the health plan rate exhibits. I certify that the information submitted above is true and correct to the best of my knowledge. I understand that the Department of Labor and Industrial Relations, Disability Compensation Division, reserves the right to audit company records in considering our request. Authorized Signature (Owner/Member/Corporate Officer) Date Print Name and Title Email Telephone No. ( ) Fax No. ( ) Visit our website at http://labor.hawaii.gov/dcd forms and instructions. (Rev. 12/17) American LegalNet, Inc. www.FormsWorkFlow.com