Esme R.

ER

Date of birth 07/11/1992 Gender Male Tobacco No State CO

Address 406 Boulder Bend, Pueblo, CO Phone (303) 555-0666

2covered

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

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

EmployeeEsme R.

Spouse coveredNo

Dependants covered1

Reimbursement tierEmployee and children

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027