Dario A.

DA

Date of birth 05/05/2002 Gender Male Tobacco No State CO

Address 580 Sagebrush Drive, Durango, CO Phone (970) 555-2960

4covered

Household

Who the allowance has to stretch across

EmployeeDario A.

Spouse coveredYes

Dependants covered2

Reimbursement tierFamily

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverSigned

Form 1095Due 28 Feb 2027