Marisa N.

MN

Date of birth 01/01/1962 Gender Male Tobacco Yes State CO

Address 648 Aspen Court, Denver, CO Phone (303) 555-3108

3covered

Carrier Kaiser Plan Silver HMO 2500 Metal Silver Coverage start Jan 1, 2026 Covering Family

Monthly premium

$588

Silver HMO 2500

Employer pays

$477

Reference plan — 80% of the lowest Silver

They pay

$111

about $51 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeMarisa N.

Spouse coveredYes

Dependants covered1

Reimbursement tierFamily

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027