Dalia J.

DJ

Date of birth 09/13/1970 Gender Male Tobacco No State CO

Address 372 Granite Avenue, Loveland, CO Phone (719) 555-0592

2covered

Household

Who the allowance has to stretch across

EmployeeDalia J.

Spouse coveredYes

Dependants covered0

Reimbursement tierEmployee and spouse

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationNot yet

Plan WaiverSigned

Form 1095Due 28 Feb 2027