Form Ers-1 - Membership Enrollment - Employees' Retirement System
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1ERS-1 (Rev 8/2014)
EMPLOYEES’ RETIREMENT SYSTEM – STATE OF HAWAII
201 Merchant Street, Suite 1400
Honolulu, Hawaii 96813-2980
Phone: 586-1735
MEMBERSHIP ENROLLMENT FORM
Clear Form
PART I (MEMBER TO COMPLETE – PLEASE PRINT)
Name __________________________________________________________S.S.No.__________________________
Last
First
Middle
Former Name (as State/County employee) __________________________________Birth Date ______/______/______
Mailing Address _________________________________________________________________ [ ] Female [ ] Male
Number / Street / PO Box
City
State
Zip Code
Marital Status [ ] Married [ ] Single
Home/Cell Phone No. __________________
Are you currently employed by another State/County agency? [ ] No [ ] Yes (Specify below)
[ ] State [ ] County of _____________ Department/Division/School ________________________________
I acknowledge receiving a copy of the brochure entitled ”Your Employees’ Retirement System” ____ (Employee Initials)
Employee Signature _____________________________________________________ Date _____________________
Complete and Attach:
Form 1-A, Designation of Beneficiary (Contributory and Hybrid Plan members)
Form EC&B-24, Claim for Service (returning members, if applicable)
PART II (EMPLOYING AGENCY TO COMPLETE)
1) Review Part I for completeness.
2) If former non-member (NS, NE, etc.) becomes a member, attach a copy of non-member Personnel Action form.
3) NEW and RETURNING Contributory (Class A, B) or Hybrid (Class H) members should complete a NEW Form 1-A,
Designation of Beneficiary.
4) Returning members should list any previous service on Form EC&B-24, Claim for Service.
5) Issue brochure “Your Employees’ Retirement System” to employee
6) Complete:
[ ] State or [ ] County of _____________
Department ________________________
Present Employment Date ____________
Group Code _______
Retirement Class Code (provided by ERS): ________
This membership Enrollment Form (ERS-1) MUST be stapled to the Personnel Action Form (for non-electronic
reporting departments only) and Form 1-A (for Contributory and Hybrid Plan members).
________________________________________________ ______________________ _____________________
Personnel Office / Staff Name (Print)
Phone Number
Date
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