UHA Forms

UHA Employer Online Application:

Instructions Fill Out the Application Complete Census Attest and Send to UHA

Welcome to UHA's online Employer Application submission system. It should take about 15 minutes to complete your application if you have the necessary information.

Please select if you are a Small or Large Group and then click the "Continue" button below to start this application process.

Small Group - In Hawaii, a Small Group is any employer with 50 or fewer full-time employees. UHA requires that that employer groups have a valid Department of Labor number.

Large Group - In Hawaii, a Large Group is any employer with 51 or more full-time employees.

Your application information will be electronically submitted to UHA Health Insurance's Sales Department and a representative will contact you shortly.

Need more time to finish your application?

Your online application session will time out after an extended period of time. The following code will enable you to resume where you left off should your browser get interrupted or time out. Please write down your Code 3KKF6L should you need to resume your session at a later time. Codes are good for 7 days.

Please click here to download and submit a paper application.

For questions or assistance:

FOR BROKERS

Client Services Department
Phone: 808-532-4000 ext. 358
Toll-free: 1-800-458-4600 ext. 358
Email: [email protected]

FOR UHA DIRECT SALES

Sales Department
Phone: 808-532-4009
Toll-free: 1-800-458-4600
Email: [email protected]

Please select Group Size on the Instructions tab.

Attestation: I certify that the information submitted in this application is accurate and complete.

Please check the affirmation box and type your name as your digital signature for this form. Enter your contact information and click Submit Application.

By checking this box and typing my name as my digital signature below, I affirm that the information provided in this Employer Application and Census forms are accurate to the best of my knowledge.
Full Name:
Title:
Email Address: Upon submit, a copy of your application will be sent to this address.
Phone Number:

Message:

Your application information will be electronically submitted to UHA Health Insurance's Sales Department and a representative will contact you shortly.