Ewan T.

ET

Date of birth 09/01/1976 Gender Male Tobacco Yes State CO

Address 244 Granite Avenue, Longmont, CO Phone (719) 555-4144

2covered

Carrier Denver Health Plan Bronze Elevate 6000 Metal Bronze Coverage start Jan 1, 2026 Covering Employee and spouse

Monthly premium

$455

Bronze Elevate 6000

Employer pays

$412

Reference plan — 70% of the lowest Silver

They pay

$43

about $20 a paycheck, 26 a year

Household

Who the allowance has to stretch across

EmployeeEwan T.

Spouse coveredYes

Dependants covered0

Reimbursement tierEmployee and spouse

What this person has signed

ICHRA Notice (90 day)On file

Annual Coverage AttestationOn file

Plan WaiverNot applicable

Form 1095Due 28 Feb 2027