Juno R.

JR

Date of birth 07/07/1980 Gender Male Tobacco No State CO

Address 546 Boulder Bend, Durango, CO Phone (303) 555-2886

2covered

Carrier Rocky Mountain Plan Silver Select 3500 Metal Silver Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$601

Silver Select 3500

Employer pays

$421

Reference plan — 70% of the lowest Silver

They pay

$180

about $83 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeJuno R.

Spouse coveredNo

Dependants covered1

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