Annika D.

AD

Date of birth 10/22/1983 Gender Female Tobacco Yes State CO

Address 457 Juniper Hollow, Pueblo, CO Phone (303) 555-0777

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

EmployeeAnnika D.

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