Beatriz L.

BL

Date of birth 07/27/1998 Gender Male Tobacco No State CO

Address 610 Boulder Bend, Pueblo, CO Phone (303) 555-1110

3covered

Household

Who the allowance has to stretch across

EmployeeBeatriz L.

Spouse coveredNo

Dependants covered2

Reimbursement tierEmployee and children

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverSigned

Form 1095Due 28 Feb 2027