Astrid H.

AH

Date of birth 06/18/1985 Gender Female Tobacco No State CO

Address 193 Pinon Street, Longmont, CO Phone (719) 555-4033

1covered

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

Monthly premium

$596

Silver Med 3200

Employer pays

$412

Reference plan — 70% of the lowest Silver

They pay

$184

about $85 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeAstrid H.

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