Hawaii Employer-Union Health Benefits Trust Fund | All EUTF Forms

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All EUTF Forms

Active Employees

Reference

2025-26 Active Reference Guide - Rev 05.01.25

Death Checklist

New Hire Enrollment Guide

Newborn Checklist

Payment of Health Benefits Premiums

ACH Deduction Authorization Agreement Form

ACH Deduction Cancellation Form

Enrollment/Update Your Info

2025-26 EC-1 Enrollment Form - Bargaining Units 11, 12, 14, 15

2025-26 EC-1 Enrollment Form - Bargaining Units 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 13

2025-26 EC-1H Enrollment Form for HSTA VB

Address Change Form for Employees - County of Hawaii

Address Change - All Employers Except for County of Hawaii

Disability Certification for Dependent Children

Domestic Partnership - Checklist and Required Documents

HIPAA Authorization Form for Release of Protected Health Information

L-1 Form - Authorized Leave of Absence Without Pay

Premium Conversion Plan

Administrative

Administrative Rules

Affidavit for Collection of Personal Property

General Affidavit

Future Retirees

Reference

2026 Retiree Highlights Guide

2025 Retiree Highlights Guide

Death Checklist

Medicare Checklist

Pre-Retirement Checklist

Medicare Part B Reimbursement

Direct Deposit Agreement Form

Payment of Health Benefits Premiums

ACH Deduction Authorization Agreement Form

ACH Deduction Cancellation Form

ERS Pension Deduction Authorization Form

ERS Pension Deduction Cancellation Form

EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/25 - 12/31/25

EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/25 - 12/31/25

Enrollment/Update Your Info

Disability Certification for Dependent Children

Domestic Partnership - Checklist and Required Documents

EC-2 Enrollment Form

HIPAA Authorization Form for Release of Protected Health Information

Administrative

Administrative Rules

Affidavit for Collection of Personal Property

General Affidavit

Retirees

Reference

2026 Retiree Highlights Guide

2025 Retiree Highlights Guide

Death Checklist

Medicare Checklist

Medicare Part B Reimbursement

Direct Deposit Agreement Form

Payment of Health Benefits Premiums

ACH Deduction Authorization Agreement Form

ACH Deduction Cancellation Form

ERS Pension Deduction Authorization Form

ERS Pension Deduction Cancellation Form

EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/25 - 12/31/25

EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/25 - 12/31/25

HSTA VB Retiree Premium Worksheet - Effective 1/1/25 - 12/31/25

Enrollment/Update Your Info

Address Change Form for Retirees

Disability Certification for Dependent Children

Domestic Partnership - Checklist and Required Documents

EC-2 Enrollment Form

EC-2H Enrollment Form

HIPAA Authorization Form for Release of Protected Health Information

Administrative

Administrative Rules

Affidavit for Collection of Personal Property

General Affidavit

Forms Index

Forms & Documents Index

Title
2025-26 EC-1 Enrollment Form - Bargaining Units 11, 12, 14, 15
2025-26 EC-1 Enrollment Form - Bargaining Units 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 13
2025-26 EC-1H Enrollment Form for HSTA VB
2025-26 Active Reference Guide - Rev 05.01.25
2026 Retiree Highlights Guide
2025 Retiree Highlights Guide
ACH Deduction Authorization Agreement Form
ACH Deduction Cancellation Form
Address Change Form for Employees - County of Hawaii Only
Address Change - All Employers Except for County of Hawaii
Address Change Form for Retirees
Administrative Rules effective 09/10/2025
Affidavit for Collection of Personal Property
Appeal Form
Chapter 87A
Death Checklist
Direct Deposit Agreement Form (Reimbursement of Medicare Part B Premiums)
Disability Certification for Dependent Children
Domestic Partnership - Checklist and Required Documents
Domestic Partnership - Required Verification Documents
EC-2 Enrollment Form
EC-2H Enrollment Form
ERS Pension Deduction Authorization Form
ERS Pension Deduction Cancellation Form
EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/25 - 12/31/25
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/25 - 12/31/25
General Affidavit
HIPAA Authorization Form for Release of Protected Health Information
HSTA VB Retiree Premium Worksheet - Effective 1/1/25 - 12/31/25
L-1 Form - Authorized Leave of Absence Without Pay
Medicare Checklist
New Hire Enrollment Guide
Newborn Checklist
Premium Conversion Plan
Pre-Retirement Checklist

Sample Documents

Medicare Part B Reminder Notice for Member Letter

Medicare Part B Reminder Notice for Spouse/Partner Letter

Medicare Part B Social Security Administration Verification Letter