Priya N.

PN

Date of birth 11/28/1979 Gender Female Tobacco No State CO

Address 176 Aspen Court, Longmont, CO Phone (303) 555-3996

3covered

Carrier Rocky Mountain Plan Silver Select 3500 Metal Silver Coverage start Jan 1, 2026 Covering Family

Monthly premium

$601

Silver Select 3500

Employer pays

$412

Reference plan — 70% of the lowest Silver

They pay

$189

about $87 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeePriya N.

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