Agnes H.

AH

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

Address 253 Juniper Hollow, Loveland, CO Phone (303) 555-0333

2covered

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

Monthly premium

$596

Silver Med 3200

Employer pays

$420

Reference plan — 70% of the lowest Silver

They pay

$176

about $81 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeAgnes H.

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