Danika P.

DP

Date of birth 04/07/1996 Gender Female Tobacco No State CO

Address 733 Larkspur Way, Grand Junction, CO Phone (970) 555-3293

1covered

Carrier Select Health Plan Silver Med 3200 Metal Silver Coverage start Jan 1, 2026 Covering Employee only

Monthly premium

$596

Silver Med 3200

Employer pays

$400

Lump sum — $400 a month

They pay

$196

about $90 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeDanika P.

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