Fillable State of Hawaii - Form LIR27 Application for Certificate of Compliance With Section 3-122-112-HAR

Fill Online, Printable, Fillable, Blank State of Hawaii - Form LIR27 Application for Certificate of Compliance With Section 3-122-112-HAR Form

Use Fill to complete blank online HAWAII (US) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

State of Hawaii - Form LIR27 Application for Certificate of Compliance With Section 3-122-112-HAR

On average this form takes 6 minutes to complete

The State of Hawaii - Form LIR27 Application for Certificate of Compliance With Section 3-122-112-HAR form is 2 pages long and contains:

  • 1 signature
  • 4 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

BROWSE HAWAII (US) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
INSTRUCTION SHEET FOR FORM LIR#27 APPLICATION FOR
CERTIFICATE OF COMPLIANCE WITH SECTION 3-122-112, HAR
Purpose
The State and County Government Purchasing Offices require vendors to submit a completed copy of this certificate.
Page 1 of this application becomes the Certificate of Approval. Facsimiles and copies of this approval form are proof of
compliance. This certificate applies to the Hawaii Unemployment Insurance, Workers’ Compensation, Temporary
Disability Insurance, and Prepaid Health Care programs.
Applications are available at the addresses below and can be downloaded from the Department of Labor and Industrial
Relations’ (DLIR) web site http://labor.hawaii.gov/ui
. From the DLIR web site, Form LIR#27 is listed under the
Unemployment Insurance Division and Disability Compensation Division.
DO NOT SUBMIT THIS PAGE
Approved, Not Applicable, or Pending certificates are valid for 6 months.
Date submitted to the DLIR _____________ (for your use)
Allow up to a total of seven (7) business days for processing.
FILING INSTRUCTIONS FOR THE
APPLICATION FOR CERTIFICATE OF COMPLIANCE WITH SECTION 3-122-112, HAR
Form LIR#27 (Rev. 10/05)
SUBMIT (mail, fax, or deliver) completed application
only to the Department of Labor and Industrial Relations,
Unemployment Insurance Division*.
*Unemployment Insurance Division
830 Punchbowl Street, Room 437
Honolulu, Hawaii 96813
Ph: (808) 586-8926
Fax: (808) 586-8929
INQUIRIES regarding the status of an application submitted seven (7) business days earlier should be directed to the
Disability Compensation Division** (Workers’ Compensation, Temporary Disability Insurance, and Prepaid Health
programs).
**Disability Compensation Division
830 Punchbowl Street, Room 209
Honolulu, Hawaii 96813
Ph: (808) 586-9200
Fax: (808) 586-9206
The Approved, Not Applicable, or Pending certificate of approval will be faxed to the applicant by the Disability
Compensation Division. Non-compliant applicants will receive Form LIR#27A instructing the applicant to contact the
appropriate program(s).
Visit our Website at http://labor.hawaii.gov/ui for ALL interactive and downloadable forms.
(Rev. 10/05)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
FORM LIR#27 APPLICATION FOR
CERTIFICATE OF COMPLIANCE WITH SECTION 3-122-112, HAR
1. APPLICANT INFORMATION: (Please Type or Print Clearly)
* Business name must be the same name submitted with the applicant’s bid or proposal.
*Applicant’s Business Name
Address City State Zip Code
DBA/Trade Name
2. IDENTIFICATION NUMBER(S): (Complete Applicable ID Numbers)
State Department of Labor Unemployment Insurance ID# Federal Employer ID# (FEIN)
-
3. EMPLOYERS: If you have a State Department of Labor Unemployment Insurance ID#, please skip question 3 only:
Do you currently have employee(s) working in the State of Hawaii?
Yes No
Do you plan to have employee(s) work in the State of Hawaii?
Yes No
SEE INSTRUCTION SHEET FOR FILING INSTRUCTIONS. Failure to provide above required information on this
application will result in a denial of this request. Unsigned applications will not be processed.
4. SIGNATURE:
NOTE: If th is application is stamped “PE NDING”, another LIR#27 must be subm itted when empl oyees are performi ng
services in the State to determine compliance with the State of Hawaii labor laws. Approval constitutes a certificate
of compliance with labor laws based on information available to the Department as of the approval date.
THIS APPLICATION BECOMES THE CERTIFICATE UPON APPROVAL.
Facsimiles and copies of this approval form are proof of compliance.
This certificate is valid for SIX (6) MONTHS from the
approval date.
Signature Date Telephone No.
( )
Fax No.
( )
Print Name
Email Address
PRINT TITLE: Corporate Officer, General Partner or Member,
Individual (Sole Proprietor), Trustee, Executor
FOR OFFICE USE ONLY
Department of Labor and Industrial Relations Approval Stamp
DLIR Log No. Date Received
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

State of Hawaii - Form LIR27 Application for Certificate of Compliance With Section 3-122-112-HAR

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document