Malik A.

MA

Brightline Electric · employee BRI-106

Date of birth 01/25/1992 Gender Male Tobacco No State CO

Address 240 Aspen Court, Golden, CO Phone (303) 555-2220

4covered

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

Monthly premium

$612

Silver PPO 3000

Employer pays

$441

Reference plan — 75% of the lowest Silver

They pay

$171

about $79 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeMalik 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