Zephyr R.

ZR

Date of birth 03/27/1970 Gender Male Tobacco No State CO

Address 206 Mesa Ridge Road, Golden, CO Phone (719) 555-2146

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

$441

Reference plan — 75% of the lowest Silver

They pay

$160

about $74 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeZephyr 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