How to Fill Out Hawaii Form HC-5: Employee Notification to Employer

To fill out Hawaii Form HC-5, download the current version (Rev. 10/2025 for calendar year 2026) from the Department of Labor and Industrial Relations, check one of the five numbered items that matches your situation, fill in the fields that item asks for, sign and date the employee section at the bottom, and hand the form to your employer.¹ The form is a single page, and each employee checks exactly one item.

What the Form Is For

Hawaii’s Prepaid Health Care Act requires most employers to provide health insurance to employees who work at least 20 hours per week. Form HC-5 is how you tell your employer, in writing, that one of five things is true: they are your principal employer, they are your secondary employer, you qualify for an exemption, you’re waiving coverage because you have your own separate plan, or you’re ending a previous exemption or waiver and want employer coverage to start.¹

The form doesn’t ask for your Social Security number, and it doesn’t ask for a policy number or group number. Older online guides sometimes say otherwise; the current form doesn’t include those fields.

Pick the Item That Matches Your Situation

Before you write anything, figure out which of the five numbered items applies. You’ll check one.

Item 1: Principal Employer

Use this if you work at least 20 hours a week for two or more employers and this employer pays you the most. Your principal employer is the one that must provide your health coverage. If you work at least 35 hours a week for an employer that isn’t the highest-paying, you may choose that employer as your principal.¹

Item 2: Secondary Employer

Use this for any other employer where you work 20 or more hours a week. Filing item 2 releases the secondary employer from having to provide coverage, because your principal employer is doing it.

Item 3: Exemption

Item 3 has four sub-checkboxes (a through d). Pick the one that applies:

You’re covered by a federal health plan such as Medicare, Medicaid, or military medical benefits for dependents and retirees (including TRICARE).²
You’re covered as a dependent under a spouse’s, parent’s, or other family member’s qualified health plan.
You’re receiving public assistance or are covered by a state plan such as MedQuest.
You’re a follower of a religious group that relies on prayer or spiritual healing, under Section 393-22.

When you claim an exemption, your employer must notify the DLIR director on a form the director prescribes.²

Item 4: Waiver

A waiver is not the same as an exemption. You waive coverage when you’ve bought your own separate health plan from a different carrier, not through your employer and not as someone else’s dependent. If you check item 4, you also have to write in the plan name and the insurance contractor name, and attach a copy of your plan for your employer to forward to the DLIR.¹ A waiver locks you into that plan for the whole 2026 calendar year.

Item 5: Ending a Previous Exemption or Waiver

Use item 5 when your outside coverage has ended or is about to end and you need your employer to start covering you. You fill in the effective date you want coverage to begin.

Fill In These Fields

Once you’ve picked your item, complete only the fields that apply to it.

At the bottom of the employee section: your printed name, signature, address, phone number, and the date.
The single item number you’re claiming. Don’t check more than one.
For item 4 only: the plan name and the insurance contractor name. Copy these from your insurance card so the spelling matches.
For item 5 only: the effective date you want employer coverage to start.

The most common mistakes are checking the wrong item and leaving the plan details blank on a waiver. Either can delay processing.

What Your Employer Does Next

The bottom section of the form is for your employer. They enter their business name, DLIR account number, address, and phone number, review your selection, and take appropriate action, meaning they either enroll you, confirm your exemption, or accept your waiver.¹ They must give you a copy of the completed, signed form and keep the original on file for at least two years.

For waivers, the employer forwards your plan documentation to the DLIR along with the HC-5. The DLIR’s forms page indicates that HC-5 submissions for 2026 go through the department’s online portal.

Renewing and Making Mid-Year Changes

Each HC-5 is valid only for the calendar year printed on the form. The DLIR’s FAQ states that the exemption notification is binding for one year and must be renewed every December 31.³ To continue an exemption or waiver into the next year, complete a fresh HC-5 for that year.

If your outside coverage ends mid-year, you don’t wait until December. Fill out a new HC-5 with item 5 checked, write in the effective date you want coverage to begin, and give it to your employer.¹ Any change of status calls for a new form.

If You Don’t File

Without a valid HC-5 on file, your employer must provide you coverage, and they can withhold part of the premium from your paycheck. The cap is 1.5 percent of your regular wages or half the premium, whichever is less, per calendar month, and withholding happens no less often than monthly.⁴ This is why a missed renewal in December often shows up as a surprise January deduction. If you’re keeping outside coverage, file the new form before the year turns over.

1
Department of Labor and Industrial Relations. Employee Notification to Employer for Calendar Year 2026 Form HC-5
2
Justia. Hawaii Revised Statutes 393-17 – Exemption of Certain Employees
3
State of Hawaii Department of Labor and Industrial Relations. Frequently Asked Questions About Prepaid Health Care
4
Department of Labor and Industrial Relations. Prepaid Health Care Administrative Rules