Alvar D.

AD

Date of birth 02/02/1993 Gender Female Tobacco No State CO

Address 797 Larkspur Way, Denver, CO Phone (970) 555-1517

1covered

Household

Who the allowance has to stretch across

EmployeeAlvar D.

Spouse coveredNo

Dependants covered0

Reimbursement tierEmployee only

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverSigned

Form 1095Due 28 Feb 2027