Anja H.

AH

Date of birth 02/14/1987 Gender Female Tobacco No State CO

Address 593 Larkspur Way, Pueblo, CO Phone (970) 555-1073

1covered

Household

Who the allowance has to stretch across

EmployeeAnja H.

Spouse coveredNo

Dependants covered0

Reimbursement tierEmployee only

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverSigned

Form 1095Due 28 Feb 2027