Tobias P.

TP

Honeycrisp Bakery · employee HON-107

Date of birth 08/28/1987 Gender Female Tobacco No State CO

Address 427 Elk Meadow Trail, Fort Collins, CO Phone (970) 555-2627

1covered

Household

Who the allowance has to stretch across

EmployeeTobias P.

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