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

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All EUTF Forms

Active Employees

Reference

2023-24 Active Reference Guide

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

2023-24 EC-1 Enrollment Form

2023-24 EC-1H Enrollment Form for HSTA VB

Address Change Form for Employees - Counties of Hawaii and Kauai Only

Address Change - All Employers Except for Counties of Hawaii and Kauai

Disability Certification for Dependent Children

Domestic Partnership - Declaration and Tax Affidavit

Domestic Partnership - Termination

HIPAA Authorization Form for Release of Protected Health Information

L-1 Form - Authorized Leave of Absence Without Pay

PCP Election Change Form (State of Hawaii Employees Only)

Administrative

Administrative Rules

Affidavit for Collection of Personal Property

General Affidavit

HSTA VB – only available to those who are currently enrolled in HSTA VB plans (formerly VEBA Members)

2022-23 EC-1H Enrollment Form for HSTA VB

2023-24 EC-1H Enrollment Form for HSTA VB

Future Retirees

Reference

2023 Retiree Highlights Guide

2024 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 1/1/23 - 12/31/23

EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/23 - 12/31/23

Enrollment/Update Your Info

2023 EC-2 Enrollment Form

2024 EC-2 Enrollment Form

Disability Certification for Dependent Children

Domestic Partnership - Declaration

Domestic Partnership - Termination

HIPAA Authorization Form for Release of Protected Health Information

Administrative

Administrative Rules

Affidavit for Collection of Personal Property

General Affidavit

Retirees

Reference

2023 Retiree Highlights Guide

2024 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 1/1/23 - 12/31/23

EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/23 - 12/31/23

HSTA VB Retiree Premium Worksheet - Effective 1/1/23 - 12/31/23

Enrollment/Update Your Info

2023 EC-2 Enrollment Form

2023 EC-2H Enrollment Form

2024 EC-2 Enrollment Form

2024 EC-2H Enrollment Form

Address Change Form for Retirees

Disability Certification for Dependent Children

Domestic Partnership - Declaration and Tax Affidavit

Domestic Partnership - Required Verification Documents

Domestic Partnership - Termination

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
2023-24 EC-1 Enrollment Form
2023-24 EC-1H Enrollment Form for HSTA VB
2023 EC-2 Enrollment Form
2023 EC-2H Enrollment Form
2023-24 Active Reference Guide
2023 Retiree Highlights Guide
ACH Deduction Authorization Agreement Form
ACH Deduction Cancellation Form
Address Change Form for Employees - Counties of Hawaii and Kauai Only
Address Change - All Employers Except for Counties of Hawaii and Kauai
Address Change Form for Retirees
Administrative Rules
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 - Declaration and Tax Affidavit
Domestic Partnership - Required Verification Documents
Domestic Partnership - Termination
ERS Pension Deduction Authorization Form
ERS Pension Deduction Cancellation Form
EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/23 - 12/31/23
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/23 - 12/31/23
General Affidavit
HIPAA Authorization Form for Release of Protected Health Information
HSTA VB Retiree Premium Worksheet - Effective 1/1/23 - 12/31/23
L-1 Form - Authorized Leave of Absence Without Pay
Medicare Checklist
New Hire Enrollment Guide
Newborn Checklist
PCP Election Change Form (State of Hawaii Employees Only)
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

Student Verification Letter