Petra F.

PF

Redtail Auto Body · employee RED-106

Date of birth 08/04/1999 Gender Female Tobacco No State CO

Address 835 Elk Meadow Trail, Grand Junction, CO Phone (970) 555-3515

3covered

Household

Who the allowance has to stretch across

EmployeePetra F.

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