Greta K.

GK

Date of birth 12/24/2003 Gender Female Tobacco No State CO

Address 971 Red Cedar Lane, Lakewood, CO Phone (719) 555-3811

1covered

Carrier Rocky Mountain Plan Bronze Summit 6900 Metal Bronze Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$449

Bronze Summit 6900

Employer pays

$365

Lump sum — $365 a month

They pay

$84

about $39 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeGreta K.

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