RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
RCUH GROUP HEALTH ENROLLMENT / CHANGE FORM (50-100% FTE)
Submit via email: RCUH_Benefits@RCUH.com or Fax: 808-956-5022
RCUH USE ONLY Authorized By:
RCUH Form B-5H rev 03/02/15
Employee Name: RCUH Employee ID #:
PRETAX Dental Insurance Coverage: Hawaii Dental Service (HDS) Select an option below:
PRETAX Medical Insurance Coverage Select an option and a plan below:
☐ New Enrollment
☐ Waive Coverage
☐ Cancel Coverage / /
☐ Add/Drop Dependent / /
☐ New Enrollment
☐ Waive Coverage*
☐ Cancel Coverage / /
☐ Add/Drop Dependent / /
Available To Hawaii Residents Only.
☐ Kaiser A Plan
☐ Kaiser B Plan
☐ HMSA Participating Provider Plan (PPO)
☐ HMSA Comprehensive Medical (CompMED)
☐ HMSA Health Plan Hawaii Plus* (HPHP)
☐ HMSA Health Plan Hawaii-Basic* (HPH)
Available To BOTH Hawaii and Out of State Residents.
☐ HMSA Health Plan Hawaii Plus* (PPO)
☐ HMSA Health Plan Hawaii-Basic* (CompMed)
*HPH/HPHP Health Center: *Primary Care Physician (PCP):
*If you do not designate a Health Center and Primary Care Physician for you & your dependents, HMSA will automatically assign it for you.
The IRS requires that we give employees an option to deduct health insurance premiums on a pre-tax (tax savings to employee) or post-tax (no tax savings to
employee) basis. If you do NOT wish to obtain tax savings from a pre-tax payroll deduction of your health insurance premium, please check here ☐.
SSN / ITIN
(Required for 12 mo
or older)
Date of Birth
(mm-dd-yyyy)
*Relationship Code: S – Spouse C – Child CU – Civil Union DP – Domestic Partner Domestic Partnership enrollment requires additional forms. See Policy 3.520 Health Plans for form.
I certify that any dependent(s) listed above are legally recognized dependents. (If a spouse or civil union partner is being covered), I certify that he/she is my legal spouse/partner
(consistent with the definition of marriage or civil union partnership as defined by the laws of the State of Hawaii). (If a DP is being covered), I certify that we meet the eligibility criteria
for DP coverage (as recognized by the State of Hawaii). (If child dependent(s) are being covered), I certify that he/she is my or my civil union partner’s natural/legally
adopted/step/foster child and under the age of 26, or (if over age 26) cannot support themselves because of a mental or phys ical disability which occurred before his/her 26th birthday.
I understand that proof of dependent status is required and agree to submit documentation by the established deadlines. I also agree to inform the RCUH if my dependent’s eligibility
status changes in the future. Failure to do so may result in cancellation of benefits, and may include termination of my employment.
I understand that following an unpaid leave of absence, I will be required to “catch up” on any missed Medical Expense Plan deductions while on leave.
Information on this application is given to obtain insurance and is true and complete to the best of my knowledge and belief. I authorize my employer to set my effective dates of
coverage and to deduct monthly employee contribution for each benefit plan from my salary, wages, or other compensation including any contribution increase, decrease, adjustment,
or cancellation as required by the Health Plan Agreement under applicable laws, policies, and procedures. I and any listed dependent agree to abide by the provisions of the service
agreement and/or medical insurance contract and health plan regulations. I agree to abide by the terms and conditions of the Group Plan Contract(s) issued to the Research Corporation
of the University of Hawaii. I have read the COBRA General Notice and I understand my rights for Continuation of Health Coverage under COBRA. I also understand that I must inform
my dependents covered under my health insurance of their rights.
I understand that failure to comply with the above or providing inaccurate information or falsifying the information contained in this form may result in disciplinary action including
termination of employment. Legal action may be brought against me and/or my Dependents/Spouse/Domestic Partner/Civil Union Partner for any losses, damages (including, but not
limited to reasonable attorneys’ fees and other legal expenses), financial or otherwise, due to false statements provided on this enrollment (or related) form or for failure to timely
notify RCUH of changed circumstances as required. In addition, any health benefits (ex., monthly premiums, claims, etc.) paid by the RCUH health plans on behalf of the Employee’s
dependents will be reversed and become the responsibility of the Employee.
Employee Signature: Date: / /
(Required for HMSA HPHP/HPH)
Under the Affordable Care Act, if you are waiving medical coverage
through RCUH, you are obligated under the Individual Mandate to obtain
coverage on your own either through a spouse, the Hawaii Health
Connector, or directly from an insurance carrier.
*Under the Affordable Care Act, if you are waiving medical coverage through RCUH, you are obligated under the Individual Mandate to obtain coverage on your own
either through a spouse, the Health Insurance Marketplace, or directly from an insurance carrier in order to prevent tax penalties by the Internal Revenue Service (IRS).
