EC-1 All Bargaining Units Enrollment Form Instructions
I. Employee Data
Select the Enrollment Type for which you are submitting the Enrollment form. Mark the New Hire box if you’re newly hired, the Qualifying Event
box if you are making changes outside of the Open Enrollment period, or the Open Enrollment box during the annual or limited Open Enrollment
period. If submitting the enrollment form for a qualifying event, give a brief description of the event and input the date the qualifying event
occurred. Common qualifying events include: Acquisition of Coverage, Adoption, Birth, Civil Union Partner, Court Order, Death, Divorce,
Domestic Partnership, Foster Child, Guardianship, Ineligible Student, Approved Leave of Absence Without Pay/Waive (LWOP/Waive),
Approved Leave of Absence Without Pay/Re-enroll (LWOP/Re-enroll), Legal Separation, Loss of Coverage, Marriage, Moving Out of the
Coverage Area, New Hire, Newly Eligible Employee, Newly Eligible Student, Reinstatement of Employment, or Termination of Domestic
Partnership. Complete all information about yourself and your spouse/partner.
II. Coverage Start Date
Carefully consider when you would like your health plans and premium deductions to begin and check the appropriate box. You can select one
of the following:
• (Option #1) Coverage starts on the date of hire or event date. Premium contributions start 1
day of the pay period in which the date of
hire or event date occurs.
• (Option #2) Coverage and contributions start 1
day of the first pay period following the date of hire or event date.
• (Option #3) Coverage and contributions start 1
day of the second pay period following the date of hire or event date.
If no selection is made, Option #1 will be used, and you will be responsible for the full premium in said pay period. Loss of Coverage and
Acquisition of Coverage must start on event date (Option #1).
III. Plan Selection
Mark all plans you wish to be enrolled in. You can choose one medical/prescription drug plan, one dental plan, and one vision plan. The
prescription drug plan is bundled with the medical plan and will depend on the medical plan you select. If you do not want any plan coverage,
mark the "Cancel/Waive" box. If no selection is made and you currently have coverage, EUTF will assume no changes are being made.
State and County Contributions: No person may be enrolled in any EUTF benefit plan as both a retiree/active employee and dependent, nor
may children be enrolled on more than one retiree/active employee plan (dual enrollment). In addition, if you and your spouse/partner are both
retirees/active employees, the employer’s contribution cannot exceed a family plan contribution in accordance with Chapter 87A-33-36, Hawaii
For State Employees Only: Premium Conversion Plan (PCP) is a voluntary benefit plan, administered by the Department of Human Resources
Development (DHRD) that allows employees to purchase their health benefit plans on a pretax basis and is offered pursuant to Section 125 of the
Internal Revenue Code. For more information, go to the DHRD website at dhrd.hawaii.gov. Please inquire with your DPO or DHRD on completing
a PCP-2 form. Mark the “Enroll” or “Cancel/Waive” box. If no election is made (i.e., left blank), the PCP election shall default to “Not Enrolled”.
For County Employees Only: Premium Conversion Plan (PCP) is administered by the Budget and Fiscal Services Department. Please contact your
Department Personnel Office for more information on available options.
IV. Dependent Information
Complete dependent information and indicate plan selection if adding, removing or continuing coverage for dependents. If you are
adding/removing more than five dependents and additional rows are needed, please attach another sheet to your enrollment form. If this is
your first time enrolling dependents in EUTF plans, please submit required proof documents including a marriage certificate if adding your
spouse or partner and a birth certificate and guardianship or adoption decree (if applicable), if adding a child(ren). If a dependent child is age 19
to 24, unmarried and covered under your dental and/or vision plans, please submit certification from the school registrar or national
clearinghouse indicating they are a full-time student. Required proof documents must be submitted to the EUTF within 45 days of the event
date. Social security numbers are required for all newly added dependents. Detailed eligibility information including required proof documents
for other life events are available online at eutf.hawaii.gov.
Use the following Relationship codes:
DPCH = Domestic Partner’s Child
GC = Guardianship or Foster Child
CUCH = Civil Union Partner’s Child
V. Other Insurance Information
If you or your dependents are covered under another health plan, you are required to complete this section. The information that you provide
does not determine how your benefits are coordinated. Coordination of Benefits rules are determined by the health benefit plans and follow
the guidelines of the National Association of Insurance Commissioner (www.naic.org).
VI. Employee Signature
Read, sign and date the form. Submit your EC-1 form to your department human resource office or enrollment designee for verification,
signature and routing to EUTF within 45 days (180 days for newborns) of the event date. DOE employees please submit your EC-1 form to the
address printed on the top right-hand corner of the enrollment form. To ensure proper processing, all required fields must be completed, and
proper documentation submitted timely.