Xiomara A.

XA

Date of birth 09/17/1982 Gender Male Tobacco No State CO

Address 780 Granite Avenue, Denver, CO Phone (719) 555-1480

4covered

Carrier Anthem Plan Silver PPO 3000 Metal Silver Coverage start Jan 1, 2026 Covering Family

Monthly premium

$612

Silver PPO 3000

Employer pays

$412

Reference plan — 70% of the lowest Silver

They pay

$200

about $92 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeXiomara A.

Spouse coveredYes

Dependants covered2

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