Complaint Form {DC-54}

Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION ENFORCEMENT BRANCH Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 INSTRUCTION SHEET FOR DC-54 COMPLAINT FORM Temporar y Disabilit y Insurance or Prepaid Healthcare MattersInstructions Please completely fill out the DC-54 COMPLAINT FORM if you wish to file a complaint on a Temporary Disability Insurance (TDI) or Prepaid Health Care (PHC) grievance. Upon receipt of your completed form, an investigator will contact you. If you have any questions, you may ask the investigator at that time. If you would like to speak to an investigator, you may call the Enforcement Branch at (808) 586-9200. If an investigator assigned to your case is unavailable, please leave your name and a daytime phone number where the investigator can contact you. Description of Complaint: Briefly describe your problem. For example: 223My employer did not provide healthcare coverage,224 or, 223I filed for TDI benefits, but my employer did not process the claim form.224 Include as much information as possible to thoroughly explain your case. A representative will contact you if additional information is necessary. The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly. If you mail your complaint, please be sure to include copies of any necessary supporting documentation (i.e. records, pay statements, etc.). If we do not receive the required documentation, processing of your complaint may be delayed. The Disability Compensation Division office will contact you before the employer is contacted to ensure that your complaint is subject to TDI and/or PHC law(s). Please remember to sign and date the form before submitting it. Delivery Information Delivery by U.S. Mail, In-Person, or via Fax Department of Labor and Industrial Relations, Disability Compensation Division Oahu Kauai Maui Princess Keelikolani Building 830 Punchbowl Street, Room 209 Honolulu, Hawaii 96813 Mailing Address: P.O. Box 3769 Honolulu, Hawaii 96812-3769 Phone: (808) 586-9200 Fax: (808) 586-9206 3060 Eiwa Street, Room 202 Lihue, Hawaii 96766 Phone: (808) 274-3351 Fax: (808) 274-3355 2264 Aupuni Street #2 Wailuku, Hawaii 96793 Phone: (808) 984-2072 Fax: (808) 984-2071 Hawaii West Hawaii 75 Aupuni Street, Room 108 Hilo, Hawaii 96720 Phone: (808) 974-6464 Fax: (808) 974-6460 A shikawa Buildin g 81-990 Halekii Street, Room 2087 Kealakekua, Hawaii 96750 If Mailing, Please Mail to This Address:P.O. Box 49, Kealakelua, Hawaii 96750 Phone: (808) 322-4808 Fax: (808) 322-4813 American LegalNet, Inc. www.FormsWorkFlow.com Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION ENFORCEMENT BRANCH Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813 DC-54 COMPLAINT FORM Temporar y Disabilit y Insurance or Prepaid Healthcare Matters Contact Information Name Work Phone ( ) Home Phone ( ) Caregiver222s Name (if applicable) Address City State Zip Code Social Security Number Occupation Employer Information Employer DBA DOL# - - Address City State Zip Code Mailing Address City State Zip Code Disability Information Temporary Disability Insurance (TDI) Carrier Complaint Filing Date Prepaid Health Care (PHC) Provider Filing Date Who Filed the Claim Date of Disability Nature of Disability Union Name and Local # (if applicable) Wage Base Hourly Salary Commission Other Complaint (use additional information sheet if necessary) TDI PHC Print Name Signature Date INTERNAL USE ONLY Received by Date Assigned to Date Action Taken Date American LegalNet, Inc. www.FormsWorkFlow.com Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms. (Rev. 10/05) DC-54 COMPLAINT FORM Page 2 of 2 Please enter any additional information (if necessary) to completely document your case. Auxiliary aids and services are available upon request. Please call: (808) 586-9200; 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 the Department222s services, programs, activities, or employment. American LegalNet, Inc. www.FormsWorkFlow.com