Osman T.

OT

Date of birth 09/05/1988 Gender Male Tobacco No State CO

Address 104 Granite Avenue, Greeley, CO Phone (719) 555-1924

2covered

Carrier Denver Health Plan Bronze Elevate 6000 Metal Bronze Coverage start Jan 1, 2026 Covering Employee and spouse

Monthly premium

$455

Bronze Elevate 6000

Employer pays

$385

Lump sum — $385 a month

They pay

$70

about $32 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeOsman T.

Spouse coveredYes

Dependants covered0

Reimbursement tierEmployee and spouse

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027