Hector C.

HC

Date of birth 03/23/2000 Gender Male Tobacco No State CO

Address 678 Mesa Ridge Road, Denver, CO Phone (719) 555-1258

1covered

Carrier Not selected Coverage would start Nov 1, 2026 Covering Employee only

Allowance waiting

$412

Reference plan — 70% of the lowest Silver

Plan chosen

None yet

nothing is reimbursed until they pick one

Household

Who the allowance has to stretch across

EmployeeHector C.

Spouse coveredNo

Dependants covered0

Reimbursement tierEmployee only

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027