Elena N.

EN

Date of birth 05/09/1972 Gender Male Tobacco No State CO

Address 108 Sagebrush Drive, Lakewood, CO Phone (970) 555-3848

2covered

Carrier Kaiser Plan Silver HMO 2500 Metal Silver Coverage start Jan 1, 2026 Covering Employee and spouse

Monthly premium

$588

Silver HMO 2500

Employer pays

$365

Lump sum — $365 a month

They pay

$223

about $103 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeElena N.

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