Direct Reimbursement Enrollment Form

Direct Reimbursement Administrative Services, LTD.

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:	Male Female
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 1-888-791-DRDP (3737) (toll free number)

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

DR Administrative Services, Inc.
20 Broadhollow Road, Suite 3007
Melville, NY 11747

631-629-4110
1-888-791-DRDP (3737) (toll free number)
631 629-4111 (fax)
1-888-791-1313 (toll free fax)
robr@dradmin.com