Anouk T.

AT

Date of birth 05/21/1966 Gender Male Tobacco No State CO

Address 784 Sagebrush Drive, Grand Junction, CO Phone (970) 555-3404

2covered

Carrier Denver Health Plan Bronze Elevate 6000 Metal Bronze Coverage start Jan 1, 2026 Covering Employee and spouse

Monthly premium

$455

Bronze Elevate 6000

Employer pays

$400

Lump sum — $400 a month

They pay

$55

about $25 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeAnouk T.

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