Direct Reimbursement Administrative Services, LTD.      
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Direct Reimbursement

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Select Applicable Benefit:

Dental Vision HRA HSA FLEX

Employer:

I. Policy Subscriber

SSN: - -
First Name:
MI:
Last Name:
Date of Birth: / /
Sex:

Address 1:
Address 2:
City:
State:
Zip:
Telephone:
Email :

Authorized Contact (s) Who Can Discuss benefit information for all covered person(s):
1.
2.
3.

 
Dependent to be covered :
Date of Birth : / /
Relationship :
Dependent to be covered :
Date of Birth : / /
Relationship :
Dependent to be covered :
Date of Birth : / /
Relationship :
Dependent to be covered :
Date of Birth : / /
Relationship :

*If more dependent fields are needed, please contact us once form has been submitted with that information 1-800-518-8811

II.

Payment: The cost per person will be determined by your employer and provided to you prior to enrollment.
 
III.
I hereby apply for the contributory coverage that I have elected above. I am aware that: I am signing up for coverage until the next enrollment period, except in the case of a change in existing benefit status or new enrollment due to new employment. I understand that this coverage will only go into effect if the employer has approved this enrollment. By my signing below, I authorize the required payroll deduction or premium invoicing (if applicable) and represent that all information shown on this form is correct. I understand my benefits may be terminated if applicable payment for benefits is not received.


Participant Signature
(by typing here you are electronically sigining)


/
Date

Effective Date of Coverage Determined by Employer


Administrative Office
Direct Reimbursement, Adm., Services, Ltd.
P.O. Box 292455
Kettering, OH 45429
Tel: 937/428-1046
Fax: 937/428-4831
email: admin@DirectReimbursement.com

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