Milo R.

MR

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

Address 886 Clearwater Road, Boulder, CO Phone (970) 555-3626

1covered

Carrier Rocky Mountain Plan Silver Select 3500 Metal Silver Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$601

Silver Select 3500

Employer pays

$412

Reference plan — 70% of the lowest Silver

They pay

$189

about $87 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeMilo R.

Spouse coveredNo

Dependants covered0

Reimbursement tierEmployee only

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027