Hugo D.

HD

Date of birth 06/10/2003 Gender Female Tobacco No State CO

Address 257 Pinon Street, Golden, CO Phone (719) 555-2257

1covered

Carrier Kaiser Permanente Plan Bronze HMO 7000 Metal Bronze Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$441

Bronze HMO 7000

Employer pays

$441

Reference plan — 75% of the lowest Silver

They pay

$0

about $0 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeHugo D.

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