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DW
Dana Whitfield
Tamarack Benefit Partners
12 active ICHRA groups

Levi H.

Honeycrisp Bakery  ·  Enrolled
LH

Levi H.

Honeycrisp Bakery · employee HON-105
Date of birth 10/02/1965 Gender Female Tobacco No State CO
Address 393 Juniper Hollow, Fort Collins, CO Phone (303) 555-2553
2covered
Carrier Select Health Plan Silver Med 3200 Metal Silver Coverage start Jan 1, 2026 Covering Employee and children
Monthly premium
$596
Silver Med 3200
Employer pays
$350
Lump sum — $350 a month
They pay
$246
about $114 a paycheck, 26 a year

Household

Who the allowance has to stretch across
EmployeeLevi H.
Spouse coveredNo
Dependants covered1
Reimbursement tierEmployee and children

Paperwork

What this person has signed
ICHRA Notice (90 day)On file
Annual Coverage AttestationOn file
Plan WaiverNot applicable
Form 1095Due 28 Feb 2027
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