Form submission 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Deceased Consumer’s Information. Fill in the First Name, Last Name, Middle Initial, Address, City/State, Zip Code, Date of Birth, and Date of Death as indicated on the Covered California Account.
3. Next, provide your Reporting Member’s Information. Ensure you include your Last Name, First Name, Middle Initial, Address, City/State, Zip Code, Daytime Phone Number (this is required), and Email Address.
4. Indicate your relationship to the deceased and answer whether you need a copy of the previous year’s IRS form 1095A. If applicable, specify if the address on the account needs updating and provide the new address.
5. Attach a copy of your identifying information. If no document is attached, ensure your signature is notarized.
6. Finally, sign and date the form at the bottom to confirm that all information provided is true and correct.

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