Lorcan C.

LC

Date of birth 11/15/1990 Gender Male Tobacco Yes State CO

Address 338 Clearwater Road, Loveland, CO Phone (970) 555-0518

1covered

Household

Who the allowance has to stretch across

EmployeeLorcan C.

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