Caleb T.

CT

Date of birth 10/19/1987 Gender Male Tobacco No State CO

Address 954 Boulder Bend, Lakewood, CO Phone (303) 555-3774

2covered

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

Monthly premium

$455

Bronze Elevate 6000

Employer pays

$365

Lump sum — $365 a month

They pay

$90

about $42 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeCaleb T.

Spouse coveredNo

Dependants covered1

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