Fairmont Specialty Hawaii - Claims Report Employer

Our claims approach provides prompt investigation, evaluation and conclusion of the claim.

It is essential that you notify us of any claim or other loss as soon as possible since nothing can be accomplished until this step is taken. Your assistance and cooperation can help speed claim handling since prompt notice gives us the chance to investigate while:

Memories are fresh.
Witnesses are more likely to be available.
Physical surroundings are unchanged.
Expert assistance can be used to help determine the cause.
Control over the claim and its costs can be exercised.
Property can be protected and preserved.

Prompt notice is also a practical necessity to minimize any potential disruption to the wages an employee may be losing while away from work. A delayed notice of an accident may also make investigation, adjustment or defense of the claim extremely difficult and costly. Fast, accurate claim reporting is in the best interest of you, your employee and us.

REPORTING CRITERIA
TIMEFRAME FOR FILING A CLAIM
REPORTING A CLAIM TO US

REPORTING CRITERIA

Immediately after a work related injury, a claim needs to be filed in all situations where any one of the following has or will result:

Lost time from work
Medical treatment has been sought

If you are unsure if an injury is work related, but one of the above criteria has been met, a claim would need to be filed.

If you are unsure if the employee has sought medical treatment, but has not lost time from work, we highly recommend you follow-up with the employee to verify this information. Although state law does not require you to file a claim where only First Aid care has been rendered, once the employee seeks medical treatment, a claim would need to be filed.

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TIMEFRAME FOR FILING A CLAIM

All claims must be filed with us within 7 calendar days from the date you have knowledge that a workers' compensation injury is being reported. This date is considered to be the "Date Reported" to you. It is defined as the date in which you were first made aware that one of the reporting criteria has been met (see Reporting Criteria, above).

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REPORTING A CLAIM TO US

Download a copy of the WC-1 "Employer's Report of Industrial Injury" here...
Complete the WC-1 form by filing out as much information as possible. The more information provided, the less questions we will have for you and the faster we will be able to investigate the claim. At minimum, the following information is required:
EMPLOYEE NAME
SOC SEC NO
DATE OF BIRTH
REGISTERED EMPLOYER
DATE INJURY/ILLNESS REPORTED
DATE OF INJURY/ILLNESS
DOL (Department of Labor) NUMBER
POLICY NO.

3. E-MAIL the WC-1 to MSubeldia@fairmontspecialty.com and copy (cc) RMolina@fairmontspecialty.com and JHigashide@fairmontspecialty.com.

*Note: By completing the WC-1 form and e-mailing it to us, you are acknowledging the authenticity of this report and authorize Fairmont Specialty^SM to file this e-generated report in lieu of an actual hand signature from you.

While e-mail is the fastest and most effective method to report a claim, if you do not have e-mail access, you may print a copy of your completed WC-1 form, sign it and send it to us by either:

FAX: (808) 523-1150

MAIL: 733 Bishop Street, #2200
Honolulu, HI 96813

*Note: Anyone who is authorized to sign the form may do so. However, in no circumstances should the injured employee sign the form.

When in doubt as to whether or not a claim should be reported to us, please contact Cory T. Okamoto, Claims Unit Manager at 526-1619 for consultation and recommendations.

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