Talia H.

TH

Date of birth 06/22/1997 Gender Female Tobacco Yes State CO

Address 933 Pinon Street, Greeley, CO Phone (719) 555-1813

1covered

Carrier Select Health Plan Silver Med 3200 Metal Silver Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$596

Silver Med 3200

Employer pays

$385

Lump sum — $385 a month

They pay

$211

about $97 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeTalia H.

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