Suri S.

SS

Date of birth 02/06/1963 Gender Female Tobacco No State CO

Address 325 Larkspur Way, Fort Collins, CO Phone (970) 555-2405

3covered

Carrier Cigna Plan Silver Connect 3000 Metal Silver Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$625

Silver Connect 3000

Employer pays

$350

Lump sum — $350 a month

They pay

$275

about $127 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeSuri S.

Spouse coveredNo

Dependants covered2

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