Simone J.

SJ

Date of birth 09/09/2000 Gender Male Tobacco No State CO

Address 512 Granite Avenue, Durango, CO Phone (719) 555-2812

2covered

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

Monthly premium

$744

Gold PPO 1500

Employer pays

$421

Reference plan — 70% of the lowest Silver

They pay

$323

about $149 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeSimone J.

Spouse coveredYes

Dependants covered0

Reimbursement tierEmployee and spouse

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027