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WC-77 Application for Hearing

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STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION

Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813

INSTRUCTION SHEET FOR FORM WC-77a
RESPONSE TO APPLICATION FOR HEARING

Instructions

Important Notice: Upon receipt of the Application of Hearing, the adverse party may file a “RESPONSE TO THE APPLICATION FOR HEARING" with the Director and shall send a copy to all parties.

Please completely fill out the WC-77a RESPONSE TO APPLICATION FOR HEARING FORM.

Completion of this form will expedite resolution of issues of controversy in a fair and judicious manner.

The Delivery Information section below lists various delivery options. Please select the most convenient method and submit the completed form accordingly.

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

Princess Keelikolani Building
830 Punchbowl Street, Room 209
Honolulu, Hawaii 96813

Mailing Address:
P.O. Box 3769
Honolulu, Hawaii 96812-3769

Phone: (808) 586-9161
Fax: (808) 586-9219

Kauai

3060 Eiwa Street, Room 202
Lihue, Hawaii 96766

Phone: (808) 274-3351
Fax: (808) 274-3355

Maui

2264 Aupuni Street #2
Wailuku, Hawaii 96793

Phone: (808) 984-2072
Fax: (808) 984-2071

Hawaii

75 Aupuni Street, Room 108
Hilo, Hawaii 96720

Phone: (808) 974-6464
Fax: (808) 974-6460

West Hawaii

Ashikawa Building
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

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

Princess Keelikolani Building, 830 Punchbowl Street, Room 209, Honolulu, Hawaii 96813

FORM WC-77a RESPONSE TO APPLICATION FOR HEARING

vs.

RESPONSE TO APPLICATION FOR HEARING

I, , above-named respondent, hereby respond to the Application for Hearing filed by on

1. RESPONSES

Response(s) to statement(s) of the issue(s) as listed on Item number 2 on page 2 of the "Application for Hearing" Form (WC-77) to be determined at the hearing.

Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.

(Rev. 10/05)

WC-77a RESPONSE TO APPLICATION FOR HEARING
Page 2 of 2

2. WITNESSES

Please list name(s) and address(es) of all witness(es) to be presented at the hearing and/or those whose testimony will be submitted via a deposition transcript. In the interest of justice and fairness, failure to list the names of witness(es) and/or whose testimony will be submitted via a deposition transcript may preclude witnesses from testifying at the hearing and/or submitting a deposition transcript.

If necessary, please list any additional names, phone numbers and addresses of witnesses on a separate sheet.

3. SPECIAL ACCOMMODATIONS

Are there any unusual, emergency or extenuating conditions that you would like the Department to consider in calendaring this case for a hearing? If yes, please briefly explain below:

Auxiliary aids and services are available upon request. Please call: (808) 586-9161; 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 Department's services, programs, activities, or employment.

Visit our Website at www.hawaii.gov/labor for ALL interactive and downloadable forms.

(Rev. 10/05)

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What the WC-77 Application for Hearing Is and when it applies

The WC-77 Application for Hearing is a formal filing used to request a contested hearing before a state workers' compensation board or commission to resolve disputes about a claim, including compensability, benefit amounts, or medical treatment. The form identifies the claimant, employer, insurer, date and nature of the injury or occupational disease, the relief requested, and supporting facts necessary to schedule a hearing. Filing procedures, allowable attachments, and outcome remedies vary by state agency rules; this guide explains common elements, completion steps, and submission options for electronic and paper workflows.

Why filing a clear WC-77 application matters

A complete, well-prepared WC-77 clarifies the dispute, preserves your right to a hearing, and helps the board schedule and resolve issues efficiently. Accurate information reduces administrative delays and the risk of dismissal or procedural sanction.

Why filing a clear WC-77 application matters

Who uses the WC-77 and how different parties rely on it

The WC-77 is used by injured workers, employers, insurers, and attorneys to initiate a hearing; each party depends on clear facts and correct service instructions when the board sets a hearing date.

  • Claimants and representatives who seek adjudication of benefits, medical disputes, or return-to-work issues.
  • Employers and insurance carriers who must respond, provide records, and prepare defenses or settlement offers.
  • Attorneys and claims adjusters who use the form to preserve appeals and present evidence at hearing.

Accurate completion benefits all participants by shortening scheduling cycles and helping adjudicators focus on the core issues raised by the application.

Core sections to include on a professional WC-77

A standard WC-77 includes claimant and employer identifiers, a concise description of the dispute, jurisdiction and claim identifiers, relief sought, supporting facts and exhibits, and signature and service information. Each section should be factual, dated, and supported by attachments where appropriate.

Claimant Details

Full legal name, contact info, date of birth, claimant file or social security number if required; use exact legal names for identity verification.

Employer and Insurer

Employer name, address, insurer or claims administrator details and claim number to ensure the board can notify all required parties.

Injury Description

Clear statement of how and when the injury or occupational disease occurred, affected body part(s), and initial treating provider.

Relief Requested

Specify the remedy sought (compensability, indemnity, medical treatment authorization, penalties, or fee disputes) with precise dates and amounts where applicable.

Evidence and Exhibits

List medical records, wage statements, employer reports, and any other attachments; reference exhibit numbers in the application for easy review.

Service and Signature

Signature, date, contact for service, and proof of service method (email, mail, or board portal) so the board can confirm proper notice to respondents.

Required fields and essential data elements

Claimant Name: Full legal name
Claimant Contact: Phone and email
Employer Name: Legal business name
Claim Number: Board or insurer claim ID
Date of Injury: MM/DD/YYYY
Relief Sought: Specific remedy requested

Practical step-by-step: completing and submitting a WC-77

Follow these steps to prepare a WC-77 that meets administrative requirements and minimizes the chance of processing delays.

  • 01
    Gather Records: Collect medical reports, employer notices, and prior filings
  • 02
    Complete Form: Fill claimant, employer, injury, relief, and exhibit list
  • 03
    Sign and Serve: Sign the form and serve all parties per board rules
  • 04
    File with Board: Submit via board portal, mail, or e‑filing per jurisdiction

How to adapt the WC-77 for online submission and review

Configure digital workflows so fields, authentication, and notifications match board and agency requirements for electronic evidence and service.

Field Configuration
Authentication Email link, SMS code, or multi-factor
Required Fields Make claimant name, date, and signature mandatory
Conditional Logic Show supporting attachments field when relief requested
Notifications Auto-send confirmations to parties after filing

Where to file or send your completed WC-77

Filing destinations vary by state; common options include the state workers' compensation board online portal, clerk's office, or certified mail to the board's designated address.

  • Board Portal: Primary electronic filing route for most jurisdictions
  • Mail: Certified mail for jurisdictions that require hardcopy service
  • Email: Permitted where board rules allow electronic service
  • In-person: Deliver to board clerk when accepted by local office

Technical considerations for digital submission and e-signing

Ensure your eSubmission method supports required file formats and secure signer authentication to satisfy board rules and evidence admissibility.

  • File Formats: PDF, DOCX accepted by most portals
  • Integrations: Connectors like NetSuite, Google Workspace, Salesforce
  • Authentication: Email code, SMS, or advanced signer verification

Choose a workflow that preserves an audit trail, stores signed PDFs in standard formats, and meets any jurisdictional authentication or retention rules.

Common timelines and filing expectations to track

Timeframes for hearings and claim filings differ by state; confirm deadlines with the relevant board and calendar your deadlines for service, responses, and hearing appearances.

File Promptly:

Submit the WC-77 as soon as dispute arises

Service Deadlines:

Serve respondents per board rules

Response Window:

Employer/insurer typically get 20–30 days to respond

Hearing Scheduling:

Board assigns date after acceptance

Appeal Periods:

Post-decision appeal windows vary by state

Common mistakes that delay WC-77 processing

  • Incomplete claimant or employer identification leading to misrouting
  • Missing dates or unclear injury description creating jurisdictional issues
  • Failure to attach or reference key medical records
  • Improper service or incomplete proof of service

Consequences of an incorrect or late WC-77

Administrative Dismissal: Board may reject incomplete filings
Delay: Processing and hearing may be postponed
Default: Failure to serve can bar relief
Evidence Exclusion: Late exhibits may be excluded
Sanctions: Possible monetary or procedural sanctions
Appeal Risk: Grounds for reversal if procedures not followed

eSignature vendor comparison for completing and submitting the WC-77

The table compares core pricing and feature considerations relevant to e-signing and submitting forms like the WC-77. signNow is listed first per vendor comparison conventions.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/yr Varies Varies Varies

Frequently asked questions about filing and e-signing a WC-77

Answers to common procedural and technical questions when preparing, signing, and submitting a WC-77 application.


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