All EUTF Forms

Active Employees


Reference
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
2020-21 EC-1 Enrollment Form
2020-21 EC-1H Enrollment Form for HSTA VB
Address Change Form for Employees
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)
2020-21 EC-1H Enrollment Form for HSTA VB

Future Retirees


Reference
2021 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 1/1/21 - 12/31/21
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/21 - 12/31/21

Enrollment/Update Your Info
2021 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
2021 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 1/1/21 - 12/31/21
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/21 - 12/31/21
HSTA VB Retiree Premium Worksheet - Effective 1/1/21 - 12/31/21

Enrollment/Update Your Info
2021 EC-2 Enrollment Form
2021 EC-2H Enrollment Form
Address Change Form for Retirees
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

Forms Index


Forms & Documents Index
Title
2019-20 EC-1 Enrollment Form
2019-20 EC-1H Enrollment Form for HSTA VB
2020-21 EC-1 Enrollment Form
2020-21 EC-1H Enrollment Form for HSTA VB
2020 EC-2 Enrollment Form
2020 EC-2H Enrollment Form
2021 EC-2 Enrollment Form
2021 EC-2H Enrollment Form
2019 Active Reference Guide
2020 Active Reference Guide
2020 Retiree Reference Guide
2021 Retiree Highlights Guide
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
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 - Termination
ERS Pension Deduction Authorization Form
ERS Pension Deduction Cancellation Form
EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/20 - 12/31/20
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/20 - 12/31/20
EUTF Retiree Premium Worksheet (Retirees Hired Prior to 7/1/2001) - Effective 1/1/21 - 12/31/21
EUTF Retiree Premium Worksheet (Retirees Hired On or After 7/1/2001) - Effective 1/1/21 - 12/31/21
General Affidavit
HIPAA Authorization Form for Release of Protected Health Information
HSTA VB Retiree Premium Worksheet - Effective 1/1/20 - 12/31/20
HSTA VB Retiree Premium Worksheet - Effective 1/1/21 - 12/31/21
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