Enrollment Forms
About Open Enrollment
If you decide to keep your current plans, you don’t need to take action. You are not required to complete any forms to continue your current coverage.
Change Requests
If you are making changes, complete and submit the EC-2 enrollment form or the EC-2H form for those enrolled in the HSTA VB benefit plans*. For open enrollment change requests, submit your completed EC-2/EC-2H enrollment form and required supporting documents to the EUTF via U.S. mail (201 Merchant St Ste 1700, Honolulu, HI 96813) or in-person by October 31, 2024, for changes to be effective January 1, 2025. The EUTF will not contact you regarding outstanding supporting documents and late submissions will not be accepted.
NOTE: Forms and required supporting documents left postmarked after October 31, 2024 will be rejected. The EUTF will send you an enrollment confirmation notice after the processing of open enrollment forms is completed.
*HSTA VB plan options were created for HSTA retirees who were enrolled in the HSTA VB retiree plans prior to January 1, 2011. These plans are no longer accepting new enrollees.
Required Supporting Documents
If you want to…
You’ll need…
Enroll Yourself
No documents required
Add a Spouse/Partner
- Marriage or Civil Union Certificate
- Domestic Partnership forms and two sets of documents showing shared residency
Add a Dependent Child
- Birth Certificate
- Guardianship Decree (if legal guardian)
- Adoption Decree (if child is placed for adoption or adopted)
Add unmarried Dependent age 19 thru 23 who becomes a full-time student
Student Certification from accredited school on school letterhead with registrar’s signature or certificate from the National Student Clearinghouse indicating full-time status. (Transcripts and class schedules are not accepted)