Teodora N.

TN

Date of birth 01/05/1974 Gender Male Tobacco No State CO

Address 508 Aspen Court, Pueblo, CO Phone (303) 555-0888

3covered

Carrier Kaiser Plan Silver HMO 2500 Metal Silver Coverage start Jan 1, 2026 Covering Family

Monthly premium

$588

Silver HMO 2500

Employer pays

$420

Lump sum — $420 a month

They pay

$168

about $78 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeTeodora N.

Spouse coveredYes

Dependants covered1

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