Rafael M.

RM

Date of birth 02/22/1969 Gender Female Tobacco Yes State CO

Address 529 Larkspur Way, Durango, CO Phone (970) 555-2849

1covered

Carrier Anthem Plan Bronze HSA 6500 Metal Bronze Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$468

Bronze HSA 6500

Employer pays

$421

Reference plan — 70% of the lowest Silver

They pay

$47

about $22 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeRafael M.

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