Ingrid S.

IS

Date of birth 10/26/1995 Gender Female Tobacco No State CO

Address 865 Juniper Hollow, Greeley, CO Phone (303) 555-1665

3covered

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

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

EmployeeIngrid S.

Spouse coveredNo

Dependants covered2

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