I
Hawaii Employer-Union Health Benefits Trust Fund
Retiree Address Change Form
Not for Active Employee Use
Complete each section thoroughly, please print clearly
Effective Date of Change: HB# or Social Security No:
DEMOGRAPHIC INFORMATION
Full Name:
Birthdate:
Last
First
M.I.
New
Mailing
Address:
City
State
Zip Code
New
Residence
Address:
City
State
Zip Code
Home Phone:
Cell Phone:
Email:
This form is for address changes only. Any enrollment changes such as adding or deleting dependents must be reported on the EC-2/EC-2H (for
HSTA VB members only) form, which is available on our website at eutf.hawaii.gov.
SIGNATURE
I certify that I am the person listed on this form and that my signature authorizes the EUTF to update my address as indicated above. This address
change supersedes all previously submitted address changes.
Signature
Date
Please submit form by mail or hand deliver to:
EUTF
201 Merchant Street, Suite 1700
Honolulu, HI 96813
Customer Service Call Center
Oahu: (808) 586-7390
Toll Free: 1 (800) 295-0089
Fax: (808) 586-2161
Address Change Rev 02/2021
Clear Form
