Perla W.

PW

Date of birth 11/03/1996 Gender Male Tobacco No State CO

Address 542 Clearwater Road, Pueblo, CO Phone (970) 555-0962

1covered

Carrier Anthem Plan Gold PPO 1500 Metal Gold Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$744

Gold PPO 1500

Employer pays

$420

Lump sum — $420 a month

They pay

$324

about $150 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeePerla W.

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