Carriers Benefit Adjustment Report {WC-3A}

WC-3A - CARRIER'S BENEFIT ADJUSTMENT REPORT. This form is used by workers' compensation insurance carriers in the State of Hawaii to request reimbursement from the Special Compensation Fund for benefit adjustments made on behalf of injured workers. Administered by the Department of Labor & Industrial Relations, Disability Compensation Division, this form documents the necessary claimant, employer, and insurance carrier information related to a specific workers' compensation case. It includes details such as the claimant's identity and injury date, the employer’s contact information, and the insurance carrier’s case data and adjuster details. By completing and signing the form, the insurance carrier certifies that the submitted information is accurate and submits a formal request for reimbursement of benefit adjustments. This form must be filed annually by January 31st of the following year, though late submissions may be accepted with good cause. www.FormsWorkflow.com