Mateo B.

MB

Inkwell Print Shop · employee INK-105

Date of birth 08/20/1963 Gender Female Tobacco No State CO

Address 159 Elk Meadow Trail, Lakewood, CO Phone (970) 555-3959

1covered

Carrier Anthem Plan Bronze HSA 6500 Metal Bronze Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$468

Bronze HSA 6500

Employer pays

$365

Lump sum — $365 a month

They pay

$103

about $48 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeMateo B.

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