Ravi C.

RC

Redtail Auto Body · employee RED-105

Date of birth 03/19/1988 Gender Male Tobacco No State CO

Address 818 Mesa Ridge Road, Grand Junction, CO Phone (719) 555-3478

1covered

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

Monthly premium

$588

Silver HMO 2500

Employer pays

$400

Lump sum — $400 a month

They pay

$188

about $87 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeRavi C.

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