Hawaii Employer-Union Health Benefits Trust Fund

The following is a list of documents you will need to enroll in your EUTF retiree health and life insurance benefits.

After filing your retirement application with the Employees’ Retirement System (ERS), please submit the following to the EUTF:

• ERS Retirement Estimate Letter*
• EUTF EC-2 Enrollment Form*

If you’re Medicare eligible (age 65+ or qualified disabled), you must also submit:

• Copy of your and/or your dependent’s Medicare card* (indicating enrollment in Medicare Part B)
• Medicare Part B Reimbursement Direct Deposit Agreement Form
• Social Security Administration letter for you and/or your dependent indicating the Medicare Part B Premium amount.

If you are adding a dependent(s), you must also submit:

• Marriage certificate*
• Birth certificate*
• Full-time Student Registrar letter or National Student Clearinghouse certificate*

If you will be paying all or a portion of your health benefit premium, you must enroll in one of the automatic premium deduction options below:

• ERS Pension Deduction*
• ACH Deduction* from your bank account

*All required forms listed above must be submitted within 60 days of your Retirement Date and before EUTF can process your and/or your dependent’s enrollment into any health benefit plan.

Optional Forms:

• Authorization for Release of Protected Health Information
• Securian Financial Group Inc. Beneficiary Designation Form