Notification of Deceased Status

Please notify us if someone with a health plan through Covered California has died.

1. Courtesy Notification of Deceased (HBEX 411a)
2. Notification of Deceased by an Enrolled Member (HBEX 411b)
3. 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.

To confirm that someone with coverage through Covered California is not deceased, please submit a signed declaration or affidavit from the affected consumer or an authorized representative that the individual is not deceased. The declaration or affidavit must include:

1. Statement that the affected consumer is not deceased.
2. Statement that the information provided is true and correct to the best of the affected consumer’s knowledge.
3. The date and the signature of the affected consumer or their authorized representative.