Nkechi J.

NJ

Date of birth 05/01/1990 Gender Male Tobacco Yes State CO

Address 172 Sagebrush Drive, Golden, CO Phone (970) 555-2072

2covered

Carrier Anthem Plan Gold PPO 1500 Metal Gold Coverage start Jan 1, 2026 Covering Employee and spouse

Monthly premium

$744

Gold PPO 1500

Employer pays

$441

Reference plan — 75% of the lowest Silver

They pay

$303

about $140 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeNkechi J.

Spouse coveredYes

Dependants covered0

Reimbursement tierEmployee and spouse

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027