Verena T.

VT

Date of birth 01/17/1968 Gender Male Tobacco No State CO

Address 304 Aspen Court, Loveland, CO Phone (303) 555-0444

3covered

Carrier Denver Health Plan Bronze Elevate 6000 Metal Bronze Coverage start Jan 1, 2026 Covering Family

Monthly premium

$455

Bronze Elevate 6000

Employer pays

$420

Reference plan — 70% of the lowest Silver

They pay

$35

about $16 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeVerena T.

Spouse coveredYes

Dependants covered1

Reimbursement tierFamily

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027