Employer-Union Health Benefits Trust Fund | All EUTF Forms

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All EUTF Forms

Active Employees

Reference

2018 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

2018-19 EC-1 Enrollment Form (All Bargaining Units Except BU 12)

2018-19 EC-1 Enrollment Form (Police Bargaining Unit 12 Only)

2018-19 EC-1H Enrollment Form for HSTA VB

Address Change Form for Employees

Civil Union - Termination

Disability Certification for Dependent Children

Domestic Partnership - Declaration and Tax Affidavit

Domestic Partnership - Termination

HIPAA Authorization Form for Release of Protected Health Information

PCP Election Change Form (State of Hawaii Employees Only)

Revised L-1 Form - Authorized Leave of Absence Without Pay with 2018 Rates

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)

2018-19 EC-1H Enrollment Form for HSTA VB

Future Retirees

Reference

2019 Reference 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 - Effective 1/1/18 - 12/31/18

EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/19 - 12/31/19

EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/19 - 12/31/19

Enrollment/Update Your Info

2019 EC-2 Enrollment Form for Retirees

2018 EC-2 Enrollment Form for Retirees

Civil Union - Termination

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

2019 Reference Guide

2018 Reference 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 - Effective 1/1/18 - 12/31/18

EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/19 - 12/31/19

EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/19 - 12/31/19

HSTA VB Retiree Premium Worksheet - Effective 1/1/18 - 12/31/18

HSTA VB Retiree Premium Worksheet - Effective 1/1/19 - 12/31/19

Enrollment/Update Your Info

2019 EC-2 Enrollment Form for Retirees

2019 EC-2H Enrollment Form for Retirees

2018 EC-2 Enrollment Form for Retirees

2018 EC-2H Enrollment Form for Retirees

Address Change Form for Retirees

Civil Union - Termination

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

Forms Index

Forms & Documents Index

Title
2018 Active Reference Guide
2018 Retiree Reference Guide
2018-19 EC-1 Enrollment Form (All Bargaining Units Except BU 12)
2018-19 EC-1 Enrollment Form (Police Bargaining Unit 12 Only)
2018-19 EC-1H Enrollment Form for HSTA VB
ACH Deduction Authorization Agreement Form
ACH Deduction Cancellation Form
Address Change Form for Employees
Address Change Form for Retirees
Administrative Rules
Affidavit for Collection of Personal Property
Appeal Form
Chapter 87A
Civil Union - Termination
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 - Termination
EC-2 Enrollment Form for Retirees
EC-2H Enrollment Form for Retirees
ERS Pension Deduction Authorization Form
ERS Pension Deduction Cancellation Form
EUTF Retiree Worksheet - Effective 1/1/18-12/31/18
EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/19 - 12/31/19
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/19 - 12/31/19
General Affidavit
HIPAA Authorization Form for Release of Protected Health Information
HSTA VB Retiree Worksheet - Effective 1/1/18-12/31/18
HSTA VB Retiree Premium Worksheet - Effective 1/1/19 - 12/31/19
Medicare Checklist
New Hire Enrollment Guide
Newborn Checklist
PCP Election Change Form (State of Hawaii Employees Only)
Pre-Retirement Checklist
Revised L-1 Form - Authorized Leave of Absence Without Pay with 2018 Rates

Sample Documents

EUTF Student Certification Letter

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