Rev: 3.44.

0
STATE OF HAWAII
Date Received
DEPARTMENT OF LABOR & INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION 12/31/2023
WC-21 APPLICATION FOR SELF-INSURANCE AUTHORIZATION

The undersigned, an employer, hereby makes application for permission to operate as a self-insurer pursuant to Chapter 386, Hawaii Revised Statutes, as amended, and
in support of such application submits the following information:

COMPANY INFORMATION
Name of Applicant – Company Name Type DOL Number

DataHouse Consulting, Inc. Sole Proprietorship AD34567890

Address City Zip Code

711 Kapiolani Blvd Ste 500 Honolulu 968135255

Nature of Business Number of Employees in Hawaii Average Monthly Payroll in Hawaii for the Past Year

Information Technology 1,000 $999,999.99

Mailing Address in Hawaii Mailing City in Hawaii Mailing Zip Code in Hawaii
711 Kapiolani Blvd Ste 500 Honolulu 968135255
ADDITIONAL ENTITIES
List below, the self-insurer and all DBA's, divisions, and subsidiaries included in its workers' compensation self-insurance plan, relationship, as well as their respective
Department of Labor (DOL) numbers. The DOL number is the account number issued by the Unemployment Insurance Division (or by the Disability Compensation
Division if the employer is not required to register with the Unemployment Insurance Division) of the State of Hawaii Department of Labor and Industrial Relations.
Company Name DOL Number Relationship Address City State Zip Code
DataHouse Asia AD34567892 Subsidiary 91 Hoang Van Danang HI 233335505
Thu Street
BUSINESS CONTACT INFORMATION
Main Point of Contact
Individual responsible for Self-Insurance Program
First Name Last Name Title

Anne Hathaway Ms.

Email Phone Number Fax Number

annehathaway@email.com (717) 857-2384 (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

Annual Report Point of Contact
Individual who will prepare the consolidated Self-Insurer's Annual Report
First Name Last Name Title

Anne Hathaway Ms.

Email Phone Number

annehathaway@email.com (717) 857-2384

Annual Report Address Annual Report City Annual Report State Annual Report Zip Code

711 Kapiolani Honolulu HI 968135255

Bond Point of Contact
Individual who will sign or be responsible for obtaining signatures on the surety bond, standby letter of credit, or security deposit
First Name Last Name Title

Anne Hathaway Ms.

Email 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

BUSINESS HISTORY IN HAWAII
Date of Commencement of Business in Hawaii If this application is approved, it is proposed that the deposit of security required will be in the form of:

12/31/1999 Standby Letter of Credit

NET PROFIT/LOSS IN HAWAII
Enter below the net profit or loss after taxes for the last five years in the State of Hawaii.
# YEAR AMOUNT
1 2023 -$19,999,999
2 2022 -$19,999,999

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3 2021 $19,999,999
4 2020 $19,999,999
5 2019 $19,999,999
EXPOSURE IN THE STATE OF HAWAII
Enter below the Workers' Compensation Exposure in the State of Hawaii in the last three years.
# YEAR PAYROLL PREMIUM BEFORE DIVIDEND EXPERIENCE LOSSES INCURRED LOSS RATIO
MODIFICATION
1 2023 $19,999,999 $19,999,999 19.5 $19,999 19.55%
2 2022 $19,999,999 $19,999,999 19.5 $19,999 19.55%
3 2021 $19,999,999 $19,999,999 19.5 $19,999 19.55%
EXCESS POLICY
Will applicant’s Workers’ At the date of this application, is there any litigation or proceeding pending or threatened, the result of which might substantially
Compensation self-insurance adversely affect the financial condition, business, or operations of the applicant or any of its subsidiaries?
program be supplemented by
an insurance policy? NO YES
If Yes, Explain
NO YES
This is an explanation for proceeding pending at the date of
this application
INSURANCE HISTORY
Has an application for workers’ compensation If Yes, On What Date? Name of Carrier
insurance ever been rejected or a policy cancelled?
10/31/2023 XYZ Hawaii Insurance Carrier
NO YES
Why?

This is the reason why the application for a workers’ compensation policy has
been cancelled
CLAIMS ADMINISTRATION
Claims administration functions (claims adjusting, etc.) will be performed by:

Self Insurer’s Own Organization

If by self insurer’s own organization:
Title First Name of Administrator Last Name of Administrator Phone Number

Dr. Stephen Strange (717) 123-6758

Address City State Zip Code

711 Kapiolani Honolulu HI 968135255

If by an outside organization:
Company Name of Third Party Administrator Phone Number

ABC Third Party Administration Company (717) 123-6758

Address City State Zip Code

711 Kapiolani Honolulu HI 968135255

REQUIRED ATTACHMENTS
(a) Independent Audit Report
(b) Financial Statements
(c) Corporation Board of Directors Resolution
SIGNATURE
I declare that this application is to operate as a self-insurer under the Workers' Compensation Law of the State of Hawaii. The undersigned has read the above
application and the facts contained therein are true, that all allegations made in such application are for the purpose of inducing the Director of the DLIR to grant
such application; and that the duties and responsibilities of the applicant under said law will be fully carried out at the time and in the manner therein provided.
Signature Date On Behalf Of

Tom Holland 12/12/2024 DataHouse Consulting, Inc.

Email Address Phone Number

tomholland123@email.com (717) 123-6758

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