Report a cancellation and request a refund with no estate

  1. Print and fill out the form.

  2. The form needs to be notarized. Don’t sign the form until the notary instructs you to do so. The notary will request a valid form of identification. i.e. passport, driver’s license, photo identification

  3. Include a copy of the death certificate when you submit the completed, notarized form to us

If the refund is expected, the refund check can be expected 7-10 business days after the documentation is received.

You can mail documents to:

Capital Blue Cross

P.O. Box 772612 
Harrisburg, PA 7177-2612


Any direct automatic monthly payment set up through a bank account (also known as Bill Payer) needs to be cancelled by you or someone else who is authorized to act on behalf of the deceased. We cannot cancel that direct payment.

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