Jonas F.

JF

Date of birth 04/28/2001 Gender Female Tobacco No State CO

Address 355 Willow Creek Lane, Loveland, CO Phone (303) 555-0555

3covered

Household

Who the allowance has to stretch across

EmployeeJonas 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