Bethany C.

BC

Date of birth 12/11/1992 Gender Female Tobacco No State CO

Address 852 Aspen Court, Boulder, CO Phone (303) 555-3552

3covered

Carrier Anthem Plan Gold PPO 1500 Metal Gold Coverage start Jan 1, 2026 Covering Family

Monthly premium

$744

Gold PPO 1500

Employer pays

$412

Reference plan — 70% of the lowest Silver

They pay

$332

about $153 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeBethany C.

Spouse coveredYes

Dependants covered1

Reimbursement tierFamily

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027