Leila E.

LE

Date of birth 01/09/1986 Gender Male Tobacco No State CO

Address 916 Aspen Court, Greeley, CO Phone (303) 555-1776

3covered

Carrier Rocky Mountain Plan Silver Select 3500 Metal Silver Coverage start Jan 1, 2026 Covering Family

Monthly premium

$601

Silver Select 3500

Employer pays

$385

Lump sum — $385 a month

They pay

$216

about $100 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeLeila E.

Spouse coveredYes

Dependants covered1

Reimbursement tierFamily

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027