Notification of Deceased Status
Please notify us if someone with a health plan through Covered California has died.
- 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.
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:
- Statement that the affected consumer is not deceased.
- Statement that the information provided is true and correct to the best of the affected consumer’s knowledge.
- The date and the signature of the affected consumer or their authorized representative.
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