Santiago E.

SE

Date of birth 05/17/1996 Gender Male Tobacco No State CO

Address 376 Sagebrush Drive, Fort Collins, CO Phone (970) 555-2516

2covered

Carrier Rocky Mountain Plan Silver Select 3500 Metal Silver Coverage start Jan 1, 2026 Covering Employee and spouse

Monthly premium

$601

Silver Select 3500

Employer pays

$350

Lump sum — $350 a month

They pay

$251

about $116 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeSantiago E.

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