NOTIFICATION OF DECEASED BY ENROLLED MEMBER 2026

1. Click ‘Get Form’ to open the NOTIFICATION OF DECEASED BY ENROLLED MEMBER in the editor.
2. Begin by filling out the 'Deceased Consumer’s Information' section. Enter the first name, last name, middle initial, address, city/state, zip code, date of birth, and 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 first name, last 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 as required. 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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