Ingeborg G.

IG

Date of birth 07/15/1962 Gender Male Tobacco Yes State CO

Address 814 Boulder Bend, Denver, CO Phone (303) 555-1554

2covered

Household

Who the allowance has to stretch across

EmployeeIngeborg G.

Spouse coveredNo

Dependants covered1

Reimbursement tierEmployee and children

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverSigned

Form 1095Due 28 Feb 2027