Cyrus A.

CA

Date of birth 05/09/1972 Gender Male Tobacco No State CO

Address 440 Sagebrush Drive, Pueblo, CO Phone (970) 555-0740

4covered

Carrier Not selected Coverage would start Nov 1, 2026 Covering Family

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

EmployeeCyrus A.

Spouse coveredYes

Dependants covered2

Reimbursement tierFamily

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027