Omar S.

OS

Date of birth 02/04/1989 Gender Male Tobacco No State CO

Address 831 Red Cedar Lane, Greeley, CO Phone (719) 555-1591

1covered

Carrier Not selected Coverage would start Nov 1, 2026 Covering Employee only

Allowance waiting

$385

Lump sum — $385 a month

Plan chosen

None yet

nothing is reimbursed until they pick one

Household

Who the allowance has to stretch across

EmployeeOmar S.

Spouse coveredNo

Dependants covered0

Reimbursement tierEmployee only

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027