NOTIFICATION OF DECEASED – BY ESTATE REPRESENTATIVE
HBEX 411c (09/17)
Additional Information cont.
Any Additional Instructions?
Please include copy of one the following documents:
Death Certificate, Obituary, Medical Record, Power of Attorney, Proof of Executor or Proof of
What legal authority do you have to act on behalf of the Consumer? Please attach one of the following
legal documents to support your authority:
1. Trust Documents - Title page, trustee page & signature page
2. Power of Attorney
3. Other Legal Documents – Court order, Consumer’s Will, etc.
Attached Copy of Estate Representative’s Identifying Information.
(If no identifying document is attached, your signature must be notarized.)
Federal Issued Identification Card
UNOFFICIAL UNLESS STAMPED BY NOTARY
Authorized Representative’s Signature
I understand Covered California may not be able to comply with my request but will provide me with a
I declare under penalty of perjury that the information on this form is true and correct.
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.