All EUTF Forms

Active Employees

Reference
2022-23 Active Reference Guide
Death Checklist
New Hire Enrollment Guide
Newborn Checklist
Open Enrollment Checklist
Payment of Health Benefits Premiums
ACH Deduction Authorization Agreement Form
ACH Deduction Cancellation Form
Enrollment/Update Your Info
2022-23 EC-1 Enrollment Form
2022-23 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
Appeal Form
Chapter 87A
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

Future Retirees

Reference
2023 Retiree Highlights Guide
Death Checklist
Department of Education (DOE) Retirement 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
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
Appeal Form
Chapter 87A
General Affidavit

Retirees

Reference
2023 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
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
Appeal Form
Chapter 87A
General Affidavit

Forms Index

Forms & Documents Index
Title
2021-22 EC-1 (Non-Ratified BU's) Enrollment Form
2021-22 EC-1 (Ratified BU's) Enrollment Form
2021-22 EC-1H Enrollment Form for HSTA VB
2022-23 EC-1 (Non-Ratified BU's) Enrollment Form
2022-23 EC-1 (Ratified BU's) Enrollment Form
2022-23 EC-1H Enrollment Form for HSTA VB
2022 EC-2 Enrollment Form
2022 EC-2H Enrollment Form
2023 EC-2 Enrollment Form
2023 EC-2H Enrollment Form
2021-22 Active Reference Guide
2022-23 Active Reference Guide
2022 Retiree Highlights 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
Department of Education (DOE) Retirement 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 1/1/22 - 12/31/22
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/22 - 12/31/22
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 1/1/22 - 12/31/22
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
Open Enrollment Checklist
PCP Election Change Form (State of Hawaii Employees Only)
Pre-Retirement Checklist
Sample Documents
Medicare Card
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