Page 4 - ABM 2021 Benefit Guide SVC HI
P. 4
Important Information Regarding
Medical
Under Chapter 393 of the Hawaii Revised
Statutes, team member working in Hawaii who
are eligible for coverage under an employer-
sponsored health plan are required to either
(i) enroll in the plan, or (ii) provide written
notiication to their employer as to why they are
not required to enroll in the plan by completing
a Form HC-5 (Employee Notiication to
Employer for Calendar Year 2021).
Form HC-5 is available for download at
abm.hrintouch.com when you decline medical
coverage. Complete, sign and date the
form and email it to the Beneits Team at
beneits@abm.com or fax it to 866.755.5398.
If your HC-5 form is not received within 15 days
after your enrollment event closes, you will be
automatically enrolled in the HMSA plan for
team member only. Coverage will be efective
retroactive to your eligibility date and will
remain in efect through December 31, 2021
unless you experience a Qualifying Life Event
(QLE). See “Life Events During the Year” for
additional information.
4 2021 Benefits Enrollment
Medical
Under Chapter 393 of the Hawaii Revised
Statutes, team member working in Hawaii who
are eligible for coverage under an employer-
sponsored health plan are required to either
(i) enroll in the plan, or (ii) provide written
notiication to their employer as to why they are
not required to enroll in the plan by completing
a Form HC-5 (Employee Notiication to
Employer for Calendar Year 2021).
Form HC-5 is available for download at
abm.hrintouch.com when you decline medical
coverage. Complete, sign and date the
form and email it to the Beneits Team at
beneits@abm.com or fax it to 866.755.5398.
If your HC-5 form is not received within 15 days
after your enrollment event closes, you will be
automatically enrolled in the HMSA plan for
team member only. Coverage will be efective
retroactive to your eligibility date and will
remain in efect through December 31, 2021
unless you experience a Qualifying Life Event
(QLE). See “Life Events During the Year” for
additional information.
4 2021 Benefits Enrollment
