Soren Z.

SZ

Date of birth 10/06/1977 Gender Female Tobacco No State CO

Address 801 Juniper Hollow, Grand Junction, CO Phone (303) 555-3441

2covered

Carrier Rocky Mountain Plan Bronze Summit 6900 Metal Bronze Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$449

Bronze Summit 6900

Employer pays

$400

Lump sum — $400 a month

They pay

$49

about $23 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeSoren Z.

Spouse coveredNo

Dependants covered1

Reimbursement tierEmployee and children

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027