Lena W.

LW

Date of birth 03/11/1964 Gender Male Tobacco No State CO

Address 882 Mesa Ridge Road, Greeley, CO Phone (719) 555-1702

1covered

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

Monthly premium

$744

Gold PPO 1500

Employer pays

$385

Lump sum — $385 a month

They pay

$359

about $166 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeLena W.

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