Isolde K.

IK

Date of birth 08/20/1963 Gender Female Tobacco No State CO

Address 491 Elk Meadow Trail, Pueblo, CO Phone (970) 555-0851

1covered

Carrier Rocky Mountain Plan Bronze Summit 6900 Metal Bronze Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$449

Bronze Summit 6900

Employer pays

$420

Lump sum — $420 a month

They pay

$29

about $13 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeIsolde K.

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