Amara N.

AN

Date of birth 09/25/1964 Gender Male Tobacco No State CO

Address 168 Granite Avenue, Loveland, CO Phone (719) 555-0148

2covered

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

Allowance waiting

$420

Reference plan — 70% of the lowest Silver

Plan chosen

None yet

nothing is reimbursed until they pick one

Household

Who the allowance has to stretch across

EmployeeAmara N.

Spouse coveredYes

Dependants covered0

Reimbursement tierEmployee and spouse

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027