Delphine B.

DB

Honeycrisp Bakery · employee HON-103

Date of birth 12/04/1985 Gender Female Tobacco No State CO

Address 359 Red Cedar Lane, Fort Collins, CO Phone (719) 555-2479

1covered

Carrier Anthem Plan Bronze HSA 6500 Metal Bronze Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$468

Bronze HSA 6500

Employer pays

$350

Lump sum — $350 a month

They pay

$118

about $54 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeDelphine B.

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