Rev: 2.71.

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STATE OF HAWAII
DEPARTMENT OF LABOR & INDUSTRIAL RELATIONS Date Received
DISABILITY COMPENSATION DIVISION 12/31/2023
FORM HC-61 Plan Name

HEALTH CARE APPLICATION FOR SELF-INSURANCE AUTHORIZATION A000023764

The undersigned, an employer, hereby makes application for permission to operate as a self-insurer pursuant to Chapter 393, Hawaii Revised Statutes, as amended, and
in support of such application provides the following information:

EMPLOYER INFORMATION
DOL Number Name of Applicant – Employer Name

AD34567890 DataHouse Consulting, Inc.

Type of Entity Other Entity Phone Number in Hawaii

Sole Proprietorship Other Entity (717) 857-2384

Mailing Address in Hawaii Mailing City Mailing State Mailing Zip Code

711 Kapiolani Blvd Ste 500 Honolulu HI 968135255

Street Address in Hawaii City in Hawaii Zip Code in Hawaii

711 Kapiolani Blvd Ste 500 Honolulu 968135255

Other Business Locations in Hawaii Nature of Business

711 Kapiolani Blvd Ste 500 Information Technology

Date Business Commenced in Hawaii Number of Covered Hawaii Employees Total Number of Employees in Hawaii

12/31/1999 1,000 1,000

MAIN POINT OF CONTACT INFORMATION
Individual in your organization that will be responsible for self-insurance program.
First Name Last Name Title

Anne Hathaway Ms.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

Point of Contact Address Point of Contact City Point of Contact State Point of Contact Zip Code

711 Kapiolani Honolulu HI 968135255

SUBSIDIARY INFORMATION
Is this a Subsidiary Company? Name of Parent Company Parent Company’s Percentage of Stock Ownership

NO YES DataHouse Consulting, Inc. 78.55%

Parent Company Address Parent Company City Parent Company State Parent Company Zip Code

711 Kapiolani Honolulu HI 968135255

Will applicant conduct business
under a name other than the
above company name?
NO YES
Additional Business Address
ADDITIONAL BUSINESSES
Additional Business Name Nature of Business
DataHouse Consulting, Inc. Information Technology
Additional Business City Additional Business State Additional Business Zip Code

711 Kapiolani Honolulu HI 968135255

NET PROFIT OR LOSS AFTER TAXES
Enter below the net profit or loss after taxes for the last five years.
# YEAR AMOUNT
1 2023 -$19,999,999
2 2022 -$19,999,999
3 2021 $19,999,999
4 2020 $19,999,999
5 2019 $19,999,999
ANNUAL FINANCIAL REPORT POINT OF CONTACT INFORMATION
Individual responsible for Self-Insurer's audited financial statements annually.
First Name Last Name Title

Anne Hathaway Ms.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

Financial Report Address Financial Report City Financial Report State Financial Report Zip Code

711 Kapiolani Honolulu HI 968135255

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 Rev: 2.71.0
Are the financial statements being Company Used to Determine Financial Solvency Relationship of Company to Percentage of Company's
submitted the employer’s own financial Applicant Ownership in Applicant
statements? DataHouse Asia Consulting,
Inc. Parent Company 78.55%
NO YES
CLAIMS ADMINISTRATION
Claims administration functions (claims adjusting, etc.) will be performed by: If Other, Explain

Self Insurer’s Own Organization This is an explanation

First Name of Administrator Last Name of Administrator Title

Stephen Strange Dr.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

Claims Administration Address Claims Administration City Claims Administration State Claims Administration Zip Code

711 Kapiolani Honolulu HI 968135255

Will the administrator have If No, Explain Limitations
the authority to promptly
provide all benefits due? This is an explanation
NO YES
Will the claims administration functions be performed at more than one location?

NO YES
LOCATION 1
First Name of Administrator Last Name of Administrator Title

Stephen Strange Dr.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

Claims Administration Address Claims Administration City Claims Administration State Claims Administration Zip Code

711 Kapiolani Honolulu HI 968135255

Will the administrator have
the authority to promptly
provide all benefits due?
NO YES
First Name of Administrator
If No, Explain Limitations
This is an explanation
LOCATION 2
Last Name of Administrator Title

Stephen Strange Dr.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

Claims Administration Address Claims Administration City Claims Administration State Claims Administration Zip Code

711 Kapiolani Honolulu HI 968135255

Will the administrator have
the authority to promptly
provide all benefits due?
NO YES
First Name of Administrator
If No, Explain Limitations
This is an explanation
LOCATION 3
Last Name of Administrator Title

Stephen Strange Dr.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

Claims Administration Address Claims Administration City Claims Administration State Claims Administration Zip Code

711 Kapiolani Honolulu HI 968135255

Will the administrator have
the authority to promptly
provide all benefits due?
NO YES
First Name of Administrator
If No, Explain Limitations
This is an explanation for why the administrator does not have
the authority to promptly provide all benefits due
LOCATION 4
Last Name of Administrator Title

Stephen Strange Dr.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

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 Rev: 2.71.0
Claims Administration Address Claims Administration City Claims Administration State Claims Administration Zip Code

711 Kapiolani Honolulu HI 968135255

Will the administrator have
the authority to promptly
provide all benefits due?
NO YES
First Name of Administrator
If No, Explain Limitations
This is an explanation
LOCATION 5
Last Name of Administrator Title

Stephen Strange Dr.

Email Address Phone Number

annehathaway@email.com (717) 857-2384

Claims Administration Address Claims Administration City Claims Administration State Claims Administration Zip Code

711 Kapiolani Honolulu HI 968135255

Will the administrator have
the authority to promptly
provide all benefits due?
NO YES
Has an application for health
care insurance ever been
rejected or a policy canceled?
NO YES
Name of Contractor
If No, Explain Limitations
This is an explanation
SUPPLEMENTAL QUESTIONS
Current Health Care Contractor(s)
XYZ Hawaii Insurance Carrier
ABC Contractor
If Yes, On What Date? Reason for Rejection/Cancellation

XYZ Hawaii Insurance Carrier 10/31/2023 This is why the application for a
workers’ compensation policy has been
cancelled
Employers with less than 1,500 total employees must obtain and maintain an excess of loss reinsurance protection for at least the first three (3) years from date that
the self-insured plan is approved by the DLIR. The coverage must include a specific deductible not to exceed $100 per member multiplied by the number of members
covered by the Company’s health plan. Employers with more than 1,500 employees need not obtain a policy. By signing this Application for Self-Insurance
Authorization, the employer agrees to obtain and maintain the reinsurance policy.
Will applicant’s health care self-insurance program be supplemented by an insurance (stop-loss) policy?

NO YES
At the date of this application, is there any litigation or proceeding pending or If Yes, Explain
threatened, the result of which might substantially adversely affect the financial
condition, business or operations of the applicant or any of its subsidiaries? This is explanation
NO YES
REQUIRED ATTACHMENTS
(a) Independent Audit Report
(b) Corporation Board of Directors Resolution
(c) Self-Insured Health Care Plan
(d) Supplemental Insurance Policy
EMPLOYER’S AGGREEMENT
The employer agrees to the following:
(a) on a monthly basis deposit to an account that will be used for medical expense reimbursements (minimum monthly funding) of at least $150 per member
and
(b) submit annually a copy of its independently audited financial statements with applicable DOL numbers and the supplemental reinsurance policy, if
required, within three (3) months following its year end to Department of Labor and Industrial Relations.
By agreeing to provide the audited financial statements for the applicant employer, the related company shall submit a letter of guarantee, upon request by the DLIR,
guaranteeing payment on all obligations or liabilities for which the applicant becomes legally obligated to pay pursuant to Chapter 393, Hawaii Revised Statutes and
the attendant administrative rules.
SIGNATURE
I declare under penalty of law that all the information provided herein is true and correct to the best of my knowledge and belief.
Signature Date Title

Tom Holland 12/12/2024 Mr.

Email Address Phone Number

tomholland123@email.com (717) 123-6758

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