Report a Death

Overview October 6, 2016

We are deeply sorry for your loss.

To report the death of an ACERA member or a beneficiary receiving a monthly retirement or continuance payment, you may call ACERA during our office hours, or use the form below; we will need answers to a few questions in order to complete our death benefits process. If you use the form below, you will automatically receive an email copy of your submission.

Once we complete our process, we will notify beneficiaries of death benefits by mail.

We’ve also created a Survivor Checklist for you.

To report the death of a spouse or domestic partner (who is not receiving a monthly retirement payment) in order to stop healthcare insurance, you may report the death by phone call or use the form below, but please mail us a letter with a copy of the death certificate (not the original), which we will need to have on file.

Report a Death Form

Your name: *

Your address: *

Your phone number: *

Your email address: *

Your relation to the deceased member or person: *

How did you learn of the member or person's death?: *

Deceased Member/Person's Information

Name of member/person deceased: *

Date of death: *

City and state where the member/person passed away: *

Is there a surviving spouse, state-registered domestic partner, or Alameda County domestic partner?: *

Yes, a surviving spouse

Yes, a surviving state-registered domestic partner

Yes, a surviving Alameda County domestic partner (the ACERA member filed a domestic partnership affidavit with Alameda County while still employed)

No, there is no surviving spouse or domestic partner

I don't know

Name of surviving spouse, state-registered domestic partner, or Alameda County domestic partner:

Address of surviving spouse, state-registered domestic partner, or Alameda County domestic partner:

Phone number of surviving spouse, state-registered domestic partner, or Alameda County domestic partner :

Are there surviving children 22 years of age or younger?: *

Yes

I don't know

If yes, please list the names and addresses of the surviving children age 22 and younger:

In the event you have contact information for any person (i.e., next of kin) of the deceased, please provide that information here (e.g., email address, cell phone number, address, home phone number, etc.):

Report a Death Form

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