Luis V.

LV

Date of birth 08/23/1981 Gender Male Tobacco No State CO

Address 389 Larkspur Way, Pueblo, CO Phone (970) 555-0629

1covered

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

Allowance waiting

$420

Lump sum — $420 a month

Plan chosen

None yet

nothing is reimbursed until they pick one

Household

Who the allowance has to stretch across

EmployeeLuis V.

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