Jalen L.

JL

Date of birth 11/03/1996 Gender Male Tobacco No State CO

Address 210 Clearwater Road, Longmont, CO Phone (970) 555-4070

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

$412

Reference plan — 70% of the lowest Silver

They pay

$200

about $92 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeJalen 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