Get Notification Of Deceased By Enrolled Member

Filling out the Notification of Deceased by Enrolled Member form is an important process for notifying Covered California about the death of a primary account holder or another enrolled member. This guide will assist you in completing the form accurately and efficiently.

Follow the steps to fill out the Notification of Deceased by Enrolled Member form online:

1. Click the ‘Get Form’ button to access the Notification of Deceased by Enrolled Member form. This will allow you to obtain the document in a convenient online format.
2. Begin by providing the deceased consumer's information. Fill in their last name, first name, middle initial, address, city/state, zip code, date of birth, and Covered California case or account number.
3. Next, provide your information as the reporting member. This section requires your last name, first name, middle initial, address, city/state, zip code, daytime phone number, and email address.
4. Specify your relationship to the deceased by selecting from the available options.
5. Indicate whether you require a copy of the previous year's IRS form 1095A by selecting 'Yes' or 'No.'
6. If the address on the account needs to be updated, check 'Yes' or 'No' and if applicable, fill in the new address including the city/state and zip code.
7. Attach a copy of your identifying information. Options include a California driver’s license, California identification card, or a federally issued identification card. If no identification is attached, your signature must be notarized.
8. If notarization is necessary, provide the date notarized and the notary public's number.
9. Finally, sign and date the form, confirming that the information provided is true and correct. Remember that your signature signifies your understanding that Covered California may not comply with your request but will respond accordingly.
10. After completing the form, you can save your changes, download it for your records, print it for submission, or share it if needed.

Complete your Notification of Deceased by Enrolled Member form online today to ensure a smooth process.