STATE OF CALIFORNIA
CALIFORNIA HEALTH BENEFIT EXCHANGE/COVERED CALIFORNIA (Exchange/CC)
NOTIFICATION OF DECEASED
HBEX 411a (09/17)
Courtesy Notification of Deceased
Please complete this form to provide Covered California with a courtesy notification for the deceased
enrollee. This change in household size will result in a termination of coverage (if the deceased was
the sole enrollee) or a redetermination of eligibility for remaining enrollees. Please allow 30 days for
processing. The form maybe be mailed or faxed to the following.
Mail: Covered California Fax: (888) 329-3700
P.O. Box 989725
West Sacramento, CA 95798-9725
Deceased Consumers Information
(As indicated on the Covered California Account)
Last Name:
First Name:
Middle Initial:
Address:
City/State:
Zip Code:
Covered California Case or Account Number:
Date of Birth:
Reporting Individual’s Information
Last Name:
Middle Initial:
Address:
Zip Code:
Daytime Phone Number (Required)
Email Address:
Are there any additional notes Covered California should add to the individuals account?
NOTIFICATION OF DECEASED
HBEX 411a (09/17)
Page 2
Required Documents
Please include copy of one the following documents:
Death Certificate, Obituary, Medical Record, Power of Attorney, Proof of Executor or Proof
of Estate.
Attached Copy of Reporting Individuals Identifying Information.
(If no identifying document is attached, your signature must be notarized.)
California Driver’s License
California Identification Card
Federal Issued Identification Card
Notary
Date Notarized:
UNOFFICIAL UNLESS STAMPED BY NOTARY
PUBLIC
Notarized By:
Notary Public Number:
Reporting Individuals Signature
Signature:
Date:
The information requested on this form is required by the California Health Benefit Exchange to
process your request and will be used solely for this purpose. Failure to provide this information may
result in the denial of your request. Legal references authorizing the collection or maintenance of the
information provided on this form include Sections 1798.22, 1798.25, 1798.27 and 1798.35
of the California Civil Code and Section 155.260(a) of the Code of Federal Regulations.
California Health Benefit Exchange, Privacy Office, 1601 Exposition Blvd, Sacramento,
CA 95815 (800) 889-3871.