JOSH GREEN, M.D. JADE T.

BUTAY
GOVERNOR DIRECTOR

SYLVIA LUKE WILLIAM G. KUNSTMAN

LIEUTENANT GOVERNOR DEPUTY DIRECTOR

STATE OF HAWAI‘I JOANN A. VIDINHAR

ADMINISTRATOR
KA MOKU‘ĀINA O HAWAI‘I
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
KA ‘OIHANA PONO LIMAHANA
DISABILITY COMPENSATION DIVISION
830 PUNCHBOWL STREET, ROOM 209
P.O. BOX 3769
HONOLULU, HAWAII 96812-3769
http://labor.hawaii.gov
Phone: (808) 586-9151 / Fax: (808) 586-9219

March 28, 2024

Test Employer 123214

505 line street
Honolulu, HI 96750

Re: Temporary Disability Insurance

GHJ-143-2412

Thank you for submitting the audited financial statements for fiscal years ending this is period
11111111111 and this is period 22222222222. A financial review of the audited financial statement was
completed to determine if continues to qualify for self-insurance under our Temporary Disability Insurance
(TDI) program. Based on our review of your company’s consolidated financial statements, we regret to inform
you that no longer qualifies for TDI self-insurance.

The following are concerns that contributed to our decision to deny your request to self-insure:

 One of the established requirements for TDI self-insurance is for a company to have sound shareholder’s
equity with positive retained earnings. Retained earnings are an indicator of a company’s ability to
remain profitable. reported accumulated deficits of ($1,254,785,415,252,414) and
($8,545,452,155,633,325) for the periods ending this is period 11111111111 and this is period
22222222222, respectively. The company does not have the required minimum surplus reserve. A
company exhibiting accumulated deficits is generally not considered for self-insurance.

 The Altman Z-score is the output of a credit-strength test that gauges a publicly-traded manufacturing
company’s likelihood of bankruptcy. An Altman Z-score close to 1.8 suggests a company might be
headed for bankruptcy, while a score closer to 3 suggests a company is in solid financial position. Test
Employer 123214 reported an Altman Z-score of 7,854,514,522,015,214.00. A company with a low
Altman Z-score is generally not considered for self-insurance.

Should you have any questions on the above concerns regarding the self-insurance denial, please contact
Cong Dang Admin, Disability Compensation Division (DCD) auditor, at (845) 214-6320. Although the 2018
audited financial statements are unsatisfactory for self-insurance status at this time, you may reapply in the

WORKERS’ COMPENSATION TEMPORARY DISABILITY INSURANCE PREPAID HEALTHCARE

dlir.workcomp@hawaii.gov dlir.tempdisabilityins@hawaii.gov dlir.prepaidhealthcare@hawaii.gov
 JOSH GREEN, M.D. JADE T. BUTAY
GOVERNOR DIRECTOR

SYLVIA LUKE WILLIAM G. KUNSTMAN

LIEUTENANT GOVERNOR DEPUTY DIRECTOR

STATE OF HAWAI‘I JOANN A. VIDINHAR

ADMINISTRATOR
KA MOKU‘ĀINA O HAWAI‘I
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
KA ‘OIHANA PONO LIMAHANA
DISABILITY COMPENSATION DIVISION
830 PUNCHBOWL STREET, ROOM 209
P.O. BOX 3769
HONOLULU, HAWAII 96812-3769
http://labor.hawaii.gov
Phone: (808) 586-9151 / Fax: (808) 586-9219
future should there be an improvement in the above stated concerns. We will gladly review any updated
audited financial statements.

Although current audited financial statements are unsatisfactory for TDI self-insurance approval, A Inc.
may still apply to be self-insured for TDI by depositing and maintaining with the State Director of Finance,
securities, or the bond of a surety company authorized to transact business in the State of Hawaii. The number
of Hawaii employees determines the dollar amount required. Test Employer 123214 would be required to post a
security deposit of $8,547,552,452,521,452 for its 1.001563269E9 employees reported under the Department of
Labor account listed above.

Should you decide not to post a security deposit or bond, you are required to purchase an approved plan
from our provider list (enclosed). The list of Insurance Carriers Authorized to Write TDI Policies in Hawaii are
also available on our website at labor.hawaii.gov/dcd. Please contact Kimberly Kaneda, DCD Health Care
Specialist, at (808) 586-9197, within two weeks from the date of this letter to inform her of the TDI plan
selected or for details in posting a deposit or surety bond.

Sincerely,

Royden T. Koito
Acting Administrator

c: Cong Dang Admin, Audit Unit

Kimberly Kaneda, Plans Acceptance Branch

WORKERS’ COMPENSATION TEMPORARY DISABILITY INSURANCE PREPAID HEALTHCARE

dlir.workcomp@hawaii.gov dlir.tempdisabilityins@hawaii.gov dlir.prepaidhealthcare@hawaii.gov