Rune C.

RC

Date of birth 11/11/1978 Gender Male Tobacco No State CO

Address 478 Clearwater Road, Durango, CO Phone (970) 555-2738

1covered

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

Monthly premium

$588

Silver HMO 2500

Employer pays

$421

Reference plan — 70% of the lowest Silver

They pay

$167

about $77 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeRune C.

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