Ondine L.

OL

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

Address 270 Mesa Ridge Road, Loveland, CO Phone (719) 555-0370

3covered

Carrier Anthem Plan Silver PPO 3000 Metal Silver Coverage start Jan 1, 2026 Covering Employee and children

Monthly premium

$612

Silver PPO 3000

Employer pays

$420

Reference plan — 70% of the lowest Silver

They pay

$192

about $89 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeOndine L.

Spouse coveredNo

Dependants covered2

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