State of Hawaii
Department of Human Services
Hawaii Premium Plus

Quarter Ending:
2010 June 30 September 30   December 31  
2011 March 31 June 30   September 30 December 31
2012 March 31 June 30   September 30 December 31
2013 March 31 June 30      
IMPORTANT: Quarterly Reports must be received by HPP no later than the 15th of the month following quarter end. Quarterly Reports are used by HPP to ensure accuracy of HPP premium reimbursements to employers and to determine recoupment, if any.
1. Employer's Federal taxpayer identification no.:

OR Social Security Number:
2. Employer/Business name
3. Provide any changes to your contact information, if applicable:
4. Did any HPP employee(s) leave employment during the quarter?
I attest that the information provided on this application is true to the best of my knowledge. If I intentionally make false statements on this application, I may have to pay penalties and/or repay any HPP reimbursements I received, pursuant to prosecution under Section 710-1063, Hawaii Revised Statutes. I give permission to the State of Hawaii to verify the information provided.
Name of person completing this form on behalf of the Employer