Dmitri M.

DM

Date of birth 10/14/2001 Gender Female Tobacco No State CO

Address 189 Juniper Hollow, Golden, CO Phone (303) 555-2109

2covered

Carrier Anthem Plan Bronze HSA 6500 Metal Bronze Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$468

Bronze HSA 6500

Employer pays

$441

Reference plan — 75% of the lowest Silver

They pay

$27

about $12 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeDmitri 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