Cleo P.

CP

Date of birth 04/20/1977 Gender Female Tobacco No State CO

Address 967 Willow Creek Lane, Greeley, CO Phone (303) 555-1887

2covered

Carrier Kaiser Permanente Plan Bronze HMO 7000 Metal Bronze Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$441

Bronze HMO 7000

Employer pays

$385

Lump sum — $385 a month

They pay

$56

about $26 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeCleo P.

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