Viktor K.

VK

Brightline Electric · employee BRI-109

Date of birth 04/08/1983 Gender Female Tobacco Yes State CO

Address 291 Willow Creek Lane, Golden, CO Phone (303) 555-2331

2covered

Household

Who the allowance has to stretch across

EmployeeViktor K.

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