Direct Reimbursement Administrative Services, LTD.      
Welcome to Direct Reimbursement
Mission
About Us
How it Works
Services
Services
Plans
Faqs
Testimonials
Companies Using Direct Reimbursement
Contact Us
UWF Enrollment
Contact Us

Direct Reimbursement

Download Printer Friendly Form

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 1-888-791-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

Copyright © 2000-2021 DR Administrative Services, Inc.
Published by Marketing Options, LLC