Alicia M.

AM

Date of birth 09/21/1983 Gender Female Tobacco No State CO

Address 138 Boulder Bend, Golden, CO Phone (303) 555-1998

2covered

Carrier Kaiser Plan Silver HMO 2500 Metal Silver Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$588

Silver HMO 2500

Employer pays

$441

Reference plan — 75% of the lowest Silver

They pay

$147

about $68 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeAlicia M.

Spouse coveredNo

Dependants covered1

Reimbursement tierEmployee and children

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027