Yusuf F.

YF

Date of birth 04/24/1989 Gender Female Tobacco No State CO

Address 495 Willow Creek Lane, Durango, CO Phone (303) 555-2775

3covered

Carrier Cigna Plan Silver Connect 3000 Metal Silver Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$625

Silver Connect 3000

Employer pays

$421

Reference plan — 70% of the lowest Silver

They pay

$204

about $94 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeYusuf F.

Spouse coveredNo

Dependants covered2

Reimbursement tierEmployee and children

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027