Enrollment Request Form

Direct Reimbursement Administrative Services, LTD.

Direct Reimbursement Enrollment Form

PLEASE PRINT THIS PAGE, FILL OUT AND SEND TO:

Direct Reimbursement Adm. Services, Ltd.
P.O. Box 292455
Kettering, OH 45429

I. Coverage Elected: Employee: Employee + One: Family:

II. Name of Employee:
Address:
City:	State: Zip:

Complete Section III only if you are electing coverage for dependents.
III. Dependent Information (For additional dependents use the back of this form)

	Date of Birth	Relationship to Employee
Spouse's Name:
Children's Name(s)*:

IV. Other Dental Coverage:
Yes No If "yes", with whom?

I hereby apply for the contributory coverage that I have elected above. I am aware that:

Any premium required will be deducted from my paycheck on a pretax basis.
I am signing up for coverage until the next enrollment period, except in the case of a change in family status.

This was explained to me prior to enrollment. By my signature below, I authorize the required payroll deduction and represent that all information shown on this form is correct.

Employee Signature: Date:
*Dependant Children between the ages of 19 and 25 must be unmarried and full-time students.

To be Completed By Employer

Date of Hire: Effective Date of Coverage:
Company Name:

Authorized Signature: Title:
If authorized signature is on file with us, you may type in your name and title, as well as employee name and authorized personnel's initials and submit electronically

If your name is not on file with us

electronically if your name is on file with us

the form and start over.