NOTIFICATION OF DECEASED BY ENROLLED MEMBER 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Deceased Consumer’s Information' section. Enter the last name, first name, middle initial, address, city/state, zip code, date of birth, and the Covered California case or account number of the deceased.
3. Next, complete the 'Reporting Member’s Information' section. Provide your current contact details including your last name, first name, middle initial, address, city/state, zip code, daytime phone number (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 or ensure your signature is notarized if no document is attached. Fill in details regarding notarization if necessary.
6. Finally, sign and date the form at the bottom to confirm that all information provided is true and correct.

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