Notification of a Deceased Covered California Member

Submit a copy of one of the following documents.

1. A written statement that the individual is not deceased. The statement must include:
   • Statement from the individual that he or she is not deceased.
   • Statement from the individual that the information provided is true and correct to the best of his or her knowledge.
   • The date and the signature of the individual who was incorrectly identified as being deceased.
2. If a consumer is deceased, please notify Covered California.
   • Courtesy Notification of Deceased (HBEX 411a)
   • Notification of Deceased by an Enrolled Member (HBEX 411b)
   • Notification of Deceased by Estate Rep. (HBEX 411c)

The following documents are accepted as proof of death:

• Copy of Death Certificate.
• Bureau of Vital Statistics records.
• Widow or survivor’s benefits on the deceased individual’s Social Security number (SSN).
• Veterans Administration or military service records.
• Hospital or medical records.
• Signed funeral director’s statement.
• Indian census records.
• Newspaper death notice (obituary).
• Insurance company records.
• Social Security records.
• Institutional records.
• Veterans Administration death payment correspondence.
• Insurance company death settlement correspondence.
• Minister or clergy statement.
• Proof of executor.
• Proof of estate.
• Probate court order (or Letter of Testamentary).
• Copy of a recorded Affidavit of Death of a Joint Tenant.
• Copy of a notarized Affidavit for Collection of Personal Property.