Fillable Courtesy Notification of Deceased Please complete this form (Covered California)

Fill Online, Printable, Fillable, Blank Courtesy Notification of Deceased Please complete this form (Covered California) Form

Use Fill to complete blank online COVERED CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Courtesy Notification of Deceased Please complete this form (Covered California)

On average this form takes 6 minutes to complete

The Courtesy Notification of Deceased Please complete this form (Covered California) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Covered California forms online.

BROWSE COVERED CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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 Consumer’s 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 Individual’s 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 Individual’s 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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Courtesy Notification of Deceased Please complete this form (Covered California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document