Fillable EC-1 All Bargaining Units Enrollment Form Instructions (Hawaii)

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EC-1 All Bargaining Units Enrollment Form Instructions (Hawaii)

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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
st
day of the pay period in which the date of
hire or event date occurs.
• (Option #2) Coverage and contributions start 1
st
day of the first pay period following the date of hire or event date.
• (Option #3) Coverage and contributions start 1
st
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
Revised Statutes.
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:
SP = Spouse
CH = Child
SC = Step Child
DP = Domestic Partner
DPCH = Domestic Partner’s Child
GC = Guardianship or Foster Child
CU = Civil Union Partner
CUCH = Civil Union Partner’s Child
DC = Disabled 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.
Submit this form to your
personnel office.
Hawaii Employer-Union Health Benefits Trust Fund
DOE employees submit to:
DOE-EBU
PO Box 2360
EUTF ACTIVE EMPLOYEE
Honolulu HI, 96804
EC-1 HEALTH BENEFITS ENROLLMENT FORM
All Bargaining Units (Excluding HSTA VB)
EMPLOYEE DATA
Complete each section thoroughly, please print clearly
Qualifying Event
Enrollment Type (
you must check one box
):
New Hire or Qualifying Event Date:
Qualifying Event Description:
Open Enrollment
Social Security No.
Full Legal
or HB#:
Name:
Last, First M.I.
Mailing
Address:
Residence
Address:
City
State
Zip Code
City
State
Zip Code
Marital Status:
Single
Marriage Date:
Married
Domestic Partner
Gender:
Male
Female
Birthdate:
Home Phone:
Spouse/Partner Name:
Cell Phone:
SSN:
Email:
Birthdate:
Note: If you will be adding your spouse or partner to your health plans, you must also indicate this information under the “Dependent Information” section.
COVERAGE START DATE
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Do not skip this section. Read the “EC-1 Enrollment Form Instructions” and complete this section before moving on. Mark one option.
Option #1 Coverage starts day of the event. Premium contributions start 1
st
day of the pay period in which the effective date of coverage
occurs. (If no option is made, Option #1 will be used.)
Option #2 Coverage and premium contributions start 1
st
day of the first pay period following event date (1
st
or the 16
th
of the month).
Option #3 Coverage and premium contributions start 1
st
day of the second pay period following event date (1
st
or the 16
th
of the month).
PLAN SELECTION EFFECTIVE 7/1/21 THROUGH 6/30/22
Medical, Chiro and Prescription Drug (select one)
HMSA PPO 90/10 Medical, Chiro and CVS Prescription Drug
Monthly Employee Premium
Cancel/Waive
Self
$494.54*
Two-Party
$1,200.96*
Family
$1,531.72*
HMSA PPO 80/20 Medical, Chiro and CVS Prescription Drug
Monthly Employee Premium
Cancel/Waive
Self
$294.14*
Two-Party
$713.96*
Family
$910.48*
HMSA PPO 75/25 Medical, Chiro and CVS Prescription Drug
Monthly Employee Premium
Cancel/Waive
Self
$83.58*
Two-Party
$202.96*
Family
$258.64*
HMSA HMO Medical, Chiro and CVS Prescription Drug
Monthly Employee Premium
Cancel/Waive
Self
$497.00*
Two-Party
$1,207.06*
Family
$1,539.58*
Kaiser HMO Comprehensive Medical, Chiro and Prescription Drug
Monthly Employee Premium
Cancel/Waive
Self
$301.68*
Two-Party
$733.22*
Family
$936.44*
Kaiser HMO Standard Medical, Chiro and Prescription Drug
Monthly Employee Premium
Cancel/Waive
Self
$85.94*
Two-Party
$208.80*
Family
$266.36*
HMA Supplemental Medical and Prescription Drug
(Must have coverage under a non-EUTF health plan to be eligible for Supplemental)
Cancel/Waive
Self
$16.66*
Two-Party
$26.52*
Family
$28.38*
Dental (select one)
Hawaii Dental Service
Monthly Employee Premium
Cancel/Waive
Self
$15.20*
Two-Party
$30.38*
Family
$49.92*
Vision (select one)
Vision Service Plan
Monthly Employee Premium
Cancel/Waive
Self
$2.46*
Two-Party
$4.56*
Family
$5.98*
Life (select one)
Securian
Cancel/Waive
Self
Premium Conversion Plan
(for State Employees only)
(if no election is made (i.e., left blank), the PCP election shall default to “Not Enrolled”)
Cancel/Waive
Enroll
*Continuation of July 1, 2020 to June 30, 2021 monthly employer contributions until a collective bargaining agreement is reached. Employees
should contact their employer or check the EUTF website at eutf.hawaii.gov for updated information regarding their premiums and contributions.
Clear Form
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I I I
I I
I
Employee’s Name:
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 Revised Statutes.
DEPENDENT INFORMATION
Complete dependent (including spouse and children) information and indicate plan selection if adding/removing dependents.
Continue Add Delete Last Name, First Name, Middle Initial Birthdate SSN Relationship Gender Medical/Rx Dental Vision
If dependents are age 19 to 23 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. Detailed eligibility information is available online at eutf.hawaii.gov.
OTHER INSURANCE INFORMATION
If you or any of your dependents are covered under another non-EUTF health plan(s), provide data below.
Type of Plan: (eg. Medical, Dental) Name of Plan: (eg. HMSA, Quest) Subscriber’s Name(s):
EMPLOYEE SIGNATURE
I am eligible for the coverage requested and declare that the individuals listed on this enrollment form are also eligible. I understand that the benefit elections
made on this application are in effect as long as I continue to meet EUTF’s eligibility requirements, or until I elect to change them subject to the provisions
of EUTF’s plan rules. I understand that if I waive coverage for myself or my dependents that I/they cannot enroll for benefits in EUTF’s Plan unless eligible
at the next Open Enrollment period or earlier, if there is a mid-year Special Enrollment event such as loss of other coverage, marriage, birth or adoption. I
have read the benefit materials, understand the limitations and qualifications of the EUTF benefits program and agree to abide by the terms and conditions
of the benefit plans elected. I authorize my employer or finance officer to make the pre-tax or after-tax deductions, adjustments or cancellations from my
salary, wages, or other compensation for the monthly employee contribution in accordance with applicable laws, rules and regulations.
A person who knowingly makes a false statement in connection with an application for any benefit may be subject to imprisonment and fines. Additionally,
knowingly making a false statement may subject a person to termination of enrollment, denial of future enrollment, or civil damages. I agree to immediately
notify the Fund in writing of any changes that would result in the loss or change of eligibility of my or any of my dependent- beneficiary’s benefits. I
understand that the Fund reserves the right to terminate benefits and to seek recovery of any overpayment of benefits resulting from my failure to provide
written notice within forty-five (45) days of the event that caused the change or ineligibility. EUTF retains the right to terminate coverage in the event of
non-payment, if payment is applicable. This form supersedes all forms and submissions previously made for EUTF coverage. I hereby declare that the
above statements are true to the best of my knowledge and belief, and I understand that I am subject to penalties for perjury.
Employee Signature
Date
Official Use Only
Department ID#
Department
Division/School
Bargaining Unit
Date Received in Office
DPO Phone Number
DPO Fax Number
DPO (or employer designee) Printed Name
Date of DPO (or employer designee) Signature
DPO (or employer designee) Signature
By signing this EC-1 form, I am attesting that this employee is eligible for EUTF benefits as per Chapter 87A, Hawaii Revised Statutes.
Comments:
Rev. 01/2021
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EC-1 All Bargaining Units Enrollment Form Instructions (Hawaii)

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Completed 8 April 2021

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