Lucian G.

LG

Date of birth 03/07/1994 Gender Male Tobacco No State CO

Address 474 Mesa Ridge Road, Pueblo, CO Phone (719) 555-0814

1covered

Carrier Denver Health Plan Bronze Elevate 6000 Metal Bronze Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$455

Bronze Elevate 6000

Employer pays

$420

Lump sum — $420 a month

They pay

$35

about $16 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeLucian G.

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