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Navigating the complexities of obtaining disability insurance benefits can often feel overwhelming for individuals facing health challenges. Central to this process in California is the Employment Development Department's DE 2501 form, a crucial document for those seeking to claim State Disability Insurance (SDI) benefits. This form serves as the primary means for workers to formally request financial support during periods when medical conditions prevent them from performing their regular work duties. The importance of accurately completing this form cannot be overstated; it provides the foundational information needed to evaluate one’s eligibility and determine the benefit amounts. From personal identification and employment details to specific medical information substantiating the disability claim, each section of the DE 2501 form requires meticulous attention to ensure a smooth process. Understanding the major aspects and requirements of this form is pivotal for individuals to navigate the claims process effectively and reduce the likelihood of facing delays in receiving support during a critical time in their lives.

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Claim for Disability Insurance (DI) Benefits

The State Disability Insurance (SDI) program provides worker-funded benefits to eligible workers who have a full or partial loss of wages due to disabilities that are not work related. The California Unemployment Insurance Code (CUIC) states that a disability is any illness or injury, either physical or mental, that prevents you from doing your regular or customary work. Disability also includes elective surgery and disabilities related to pregnancy or childbirth.

Please read instruction and information pages (A through D) before completing the enclosed forms.

For faster processing, file your claim using SDI Online at edd.ca.gov. If you file online, do NOT mail this form to the Employment Development Department (EDD).

DO NOT COMPLETE THIS FORM IF YOU ARE:

Insured by a Voluntary Plan. Ask your employer for the proper forms.

Filing for Non-Industrial Disability Insurance benefits. State government employees refer to your personnel office.

If you cannot complete this form due to your disability, or if you are an authorized representative filing for benefits on behalf of an incapacitated or deceased claimant, call 1-800-480-3287 or visit the EDD website to send an online message using Ask EDD at askedd.edd.ca.gov.

HOW TO COMPLETE THIS FORM

Use black ink only.

Type or write clearly within the boxes provided.

Enter your Social Security number on all pages of the claim form including attachments.

Do not fax the form.

Mail the completed form to the EDD in the envelope provided. Submit your claim no earlier than nine days after the first day your disability begins, but no later than 49 days after your disability begins. You may lose benefits if your claim is late.

1.Complete ALL items in “PART A – CLAIMANT’S STATEMENT” and sign box A40. Errors or missing information may cause your claim to be returned and delay payment. For box A13, the United States Postal Service will not deliver mail to a private mail box unless it is preceded by the initials “PMB.”

2.Have your physician/practitioner complete and sign “Part B – PHYSICIAN/PRACTITIONER’S CERTIFICATE.” Certification may be made by a licensed physician or practitioner authorized to certify to a patient’s disability or serious health condition pursuant to CUIC, section 2708. If you are under the care of an accredited religious practitioner, obtain a Claim for Disability Insurance Benefits - Religious Practitioner’s Certificate (DE 2502) by calling 1-800-480-3287 and ask your religious practitioner to complete and sign it. Rubber stamp signatures are not accepted.

3.You should carefully decide the date you want your claim to begin because it may affect your benefit amount. See “YOUR BENEFIT AMOUNTS” on page B for information.

4.If you have a work-related disability, complete questions A31 to A38. If your workers’ compensation claim has been accepted, denied, or delayed, please include the status letter from the carrier.

5.Place the completed, signed form(s) in the envelope provided. A claim is complete when “PART A – CLAIMANT’S STATEMENT” and “PART B – PHYSICIAN/PRACTITIONER’S CERTIFICATE” are received. Claims are generally processed within 14 days.

6.Keep these instructions and information pages (A through D) for future reference.

The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling 1-866-490-8879 (voice). TTY users, please call the California Relay Service at 711.

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 1 of 13

Instruction & Information A

BASIC ELIGIBILITY. DI benefits can be paid only after you meet all of the following requirements:

You must be unable to do your regular or customary work for at least eight consecutive days.

You must be employed or actively looking for work at the time you become disabled.

You must have lost wages because of your disability or, if unemployed, have been actively looking for work.

You must have earned at least $300 in wages from which SDI deductions were withheld during your established base period (see “YOUR BENEFIT AMOUNTS” in the next column).

You must be under the care and treatment of a licensed physician/ practitioner or accredited religious practitioner during the first eight days of your disability. (The beginning date of a claim can be adjusted to meet this requirement.) You must remain under care and treatment to continue receiving benefits.

You must complete and submit a claim form within 49 days of the date you became disabled or you may lose benefits.

Your physician/practitioner must complete the medical certification of your disability. A licensed midwife or nurse- midwife may complete the medical certification for disabilities related to normal pregnancy or childbirth. If you are under the care of a religious practitioner, request a DE 2502 from the SDI office. Certification by a religious practitioner is acceptable only if the practitioner has been accredited by the EDD.

We may require an independent medical examination to determine your initial or continuing eligibility.

INELIGIBILITY. You may apply for benefits even if you are not sure you are eligible. If you are found to be ineligible for all or part of a period claimed, you will be notified of the ineligible period and the reason. You may not be eligible for DI benefits if you:

are claiming or receiving Unemployment Insurance or Paid Family Leave benefits.

became disabled while committing a crime resulting in a felony conviction.

are receiving Workers’ Compensation benefits at a weekly rate equal to or greater than the SDI rate.

are in jail or prison because you were convicted of a crime.

are a resident in an alcoholic recovery home or drug-free residential facility that is not both licensed and certified by the state in which the facility is located.

fail to submit to an independent medical examination when requested to do so.

FRAUD. Under sections 2101, 2116, and 2122 of the California Unemployment Insurance Code, it is a violation to willfully make a false statement or knowingly conceal a material fact in order to obtain the payment of any benefits, such violation being punishable by imprisonment and/or by a fine not exceeding $20,000 or both. To detect and discourage fraud, SDI continually monitors claim payments, vigorously investigates suspicious activity, and will seek restitution and conviction through prosecution.

YOUR RESPONSIBILITIES.

File your claim and other forms completely, accurately, and in a timely manner. If a form is late, attach a written explanation of the reason(s) to the form.

Thoroughly read the instructions on this and all other forms your receive from SDI. If you are not sure what is required, contact the SDI office.

Report to SDI in writing, electronically, or by telephone any:

-change of address or telephone number.

-return to part-time or full-time work.

-recovery from your disability.

-income you receive.

Keep an appointment for an independent medical examination, if requested.

Include your name and Social Security number or Claim ID number on all correspondence.

YOUR RIGHTS. Information about your claim will be kept confidential, except for the purposes allowed by law. California Civil Code, section 1798.34, gives you the right to inspect any personal records maintained about you by the EDD. Section 1798.35 permits you to request that the record be corrected if you believe

it is not accurate, relevant, timely, or complete. Certain types of information that would generally be considered personal are exempt from disclosure to you: medical or psychological records where knowledge of the contents might be harmful to the subject (Civil Code, section 1798.40); records of active criminal, civil, or administrative investigations (Civil Code, section 1798.40). If you are denied access to records which you believe you have a right to inspect or if your request to amend your records is refused, you may file an appeal with the SDI office. You may request a copy of your file by calling SDI at 1-800-480-3287.

You also have the right to appeal any disqualification, overpayment, or penalty. Specific instructions on how to appeal will be provided on any appealable document you receive. If you file an appeal and you remain disabled, you must continue to complete and return continued claim certifications.

YOUR BENEFIT AMOUNTS. Your claim begins on the date your disability began. SDI calculates your weekly benefit amount using your base period. The date your disability began determines your base period, unless the claim effective date is adjusted by SDI. If you want your claim to begin later so that you will have a different base period, please call SDI at 1-800-480-3287 before you file your claim.

This base period covers 12 months and is divided into four consecutive quarters. Your base period includes wages subject to SDI tax which you were paid approximately 5 to 17 months before your disability claim begins. Your base period does not include wages being paid at the time the disability begins. For a disability claim to be valid, you must have at least $300 in wages in the base period. Using the following, you may determine the base period for your claim.

If your claim begins in January, February, or March, your base period is the 12 months ending last September 30.

If your claim begins in April, May, or June, your base period is the 12 months ending last December 31.

If your claim begins in July, August, or September, your base period is the 12 months ending last March 31.

If your claim begins in October, November, or December, your base period is the 12 months ending last June 30.

The quarter of your base period in which you were paid the highest wages determines your weekly benefit amount. You may not change the beginning date of your claim or adjust your base period after you have established a valid claim.

Your daily benefit amount is your weekly benefit amount divided by seven. Your maximum benefit amount is 52 times your weekly benefit amount or the total wages subject to SDI tax paid in your base period, whichever is less. Exceptions are as follows:

For employers and self-employed individuals who elect SDI coverage, the maximum benefit amount is 39 times the weekly rate.

For residents in a state licensed and certified alcoholic recovery home or drug-free residential facility, the maximum payable period is 90 days. (However, disabilities related to or caused by acute or chronic alcoholism or drug abuse which are being medically treated do not have this limitation.)

Contact the SDI office to inquire and provide additional information if your situation fits any of these circumstances: If you do not have sufficient base period wages and you remain disabled, you may be able to establish a valid claim by using a later beginning date. If you do not have enough base period wages and you were actively seeking work for 60 days or more in any quarter of the base period, you may be able to substitute wages paid in prior quarters. Additionally, you may be entitled to substitute wages paid in prior quarters either to make your claim valid or to increase your benefit amount if during your base period you were in the U.S. military service, received Workers’ Compensation benefits, or did not work because of a labor dispute.

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 2 of 13

Instruction & Information B

HOW BENEFITS ARE PAID. When your completed “PART A – CLAIMANT’S STATEMENT” and “PART B – PHYSICIAN/ PRACTIONER’S CERTIFICATE” are received, the SDI office will notify you by mail of your weekly and maximum benefit amounts and may request additional information if needed to determine your eligibility. If you are eligible to receive benefits, you have an option in how you receive your benefit payments. The EDD issues benefit payments by the EDD Debit CardSM or by check. The EDD Debit Card is the fastest and most secure way to receive your benefits. You do not have to accept the EDD Debit Card, to receive your benefits by check mailed from the EDD allow 7-10 days for delivery by US mail. The majority of claims are processed and payments are issued within 14 days of receipt of both the claimant’s and the physician/practitioner’s portions of the claim.

The first seven days of your claim is a non-payable waiting period.

If you are eligible for further benefits, additional payments will be sent automatically or a continued claim certification form for the next period will be enclosed. Usually, the certification periods are for two weeks; however, the period will vary under certain circumstances. You will be paid 1/7 of your weekly benefit amount for each calendar day you are eligible unless benefits are reduced for some reason. (See “BENEFIT REDUCTIONS” below.) If you receive DI benefits in place of Unemployment Insurance or Paid Family Leave benefits, the amounts paid will be reported to the Internal Revenue Service. Contact the Internal Revenue Service for more specific tax information.

BENEFIT REDUCTIONS. Under certain circumstances, you may not be eligible for a period of your claim or you may be entitled only to partial benefits. SDI will determine whether or not benefits must be reduced. The types of income shown in the following list should be reported to SDI even though they may not always affect your benefits. Failure to report your income could result in an overpayment, penalties, and a false statement disqualification.

Sick leave pay

Self-employment income

Military pay

Commissions

Wages, including modified duty wages

Residuals

Part-time work income

Bonuses

Workers’ Compensation benefits

Insurance settlements

Holiday pay

In addition, your benefits may be reduced because of a prior Unemployment Insurance, Paid Family Leave, or DI overpayment or for delinquent court-ordered support payments.

BENEFIT INTERRUPTION and TERMINATION. A Notice of Final Payment will be issued when records show you have:

been paid to your physician/practitioner’s estimated date of recovery. If you are still disabled, ask your physician/ practitioner to complete and return the Physician/Practitioner’s Supplementary Certificate (DE 2525XX) (enclosed with the Notice of Final Payment).

recovered or returned to your work. If you return to work and become disabled again, immediately submit a new claim form and report the date(s) you worked.

OVERPAYMENT. An overpayment results when you receive DI benefits you were not entitled to receive. Once SDI determines that you were overpaid, the SDI office will contact you to explain the reason for your overpayment. It is important that you complete and return all information requests, as there are some instances when an overpayment can be waived. If it is determined that you were overpaid and the overpayment cannot be waived, you must repay this money. Benefits issued after an overpayment is established may be reduced by 25 to 100 percent to collect your overpayment. You will receive a Notice of Overpayment Offset (DE 826) if a reduction is taken for either a DI, Paid Family Leave, or Unemployment Insurance overpayment.

DISQUALIFICATION. All available information will be considered before paying or disqualifying your claim. Benefits will be paid only for the days to which you are entitled. If payment of benefits is denied or reduced, you will be issued a Notice of Determination (DE 2517) stating the reason for the disqualification and the time period.

If you deliberately report incorrect information or if you willfully omit or withhold information, false statement disqualifications of up to 92 days are assessed. This may apply if you accept disability benefit payments you know include days for which you should not be paid, such as days after you returned to work. In addition, any resulting overpayment will be increased by a 30 percent penalty assessment.

SPECIAL CIRCUMSTANCES.

Work-related Disability. If you have suffered a work-related injury or illness, report it to your employer and have your physician/ practitioner submit a report to your employer’s Workers’ Compensation insurance carrier. If the Workers’ Compensation insurance carrier delays or refuses payments, SDI may pay you benefits while your case is pending. However, SDI will pay benefits only for the period you are disabled and will file a lien to recover benefits paid. NOTE: SDI and Workers’ Compensation are two separate programs. You cannot legally be paid full benefits from both programs for the same period. However, if your Workers’ Compensation benefit rate is less than your SDI rate, SDI may pay you the difference between the two rates. For Workers’ Compensation information and assistance, call your local Workers’ Compensation Appeals Board office. You will find their listing

in the State government pages of your telephone book under California, State of; Industrial Relations Department; Workers’ Compensation Appeals Board.

Pregnancy. As with any medical condition, the disability period begins with the first day you are unable to do your regular

or customary work. DI benefits will be paid for the period of time supported by your physician/practitioner’s certification. Pregnancy-related disability claims should NOT be submitted until after the eighth day following the date your physician/practitioner certifies you are disabled.

Bonding with a New Child. Contact the EDD’s Paid Family Leave program at 1-877-238-4373. With the final DI benefit payment issued to a new mother, a transition bonding claim form, Claim for Paid Family Leave (PFL) Benefits – New Mother (DE 2501FP) will be sent automatically by mail or electronically to your online State Disability Insurance Online Service account if established.

Child Support Questions. Contact the Department of Child Support Services at 1-866-249-0773.

Spousal or Parental Support Questions. Contact the District Attorney’s office administering the court order.

Family Care. If a family member must stop work to care for you, or if you stop work to care for a seriously ill family member, please visit edd.ca.gov or contact the EDD’s Paid Family Leave program at 1-877-238-4373 for more information.

Long-term or Permanent Disability. If you expect your disability to be long-term or permanent, contact the Social Security Administration well before you exhaust your DI benefits. For information, call the Social Security Administration toll-free at 1-800-772-1213.

Rehabilitation. If you have a disability which prevents you from getting or keeping a job, the Department of Rehabilitation may be able to assist you with vocational training, education, career opportunities, independent living, and use of assistive technology.

Job Training. Contact a One-Stop Career Center (1-877-872-5627 or servicelocator.org) for services available in your area.

Seeking Work. Contact the EDD for information and assistance concerning employment opportunities and Unemployment Insurance benefits.

Death of Claimant. If a person receiving DI benefits dies, an heir or legal representative should report the death to SDI. Benefits are payable through date of death.

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 3 of 13

Instruction & Information C

EDD Debit Card Fee Disclosures

Monthly Fee

Per purchase

ATM withdrawal

Cash reload

$0

$0

$0 in-network

N/A

 

 

$1.00** out-of-network

 

 

 

 

 

ATM balance inquiry

 

 

$0

 

 

 

 

Customer service

 

 

$0 per call

 

 

 

 

Inactivity

 

 

$0

We charge 5 other types of fees. Here are some of them:

 

 

 

 

Replacement card, express delivery

 

$10.00

 

 

 

Each international transaction

 

2%

*This document entitled ‘Fee Disclosure and Other Important Disclosures’ is included with, and incorporated in, the California Employment Development Department Debit Card Account Agreement.

**Fees can be lower depending on how and where this card is used.

See the materials you received with your card for free ways to access your funds and balance information.

No overdraft/credit features.

Your funds are eligible for FDIC insurance.

For more information about prepaid cards, visit cfpb.gov/prepaid.

Find details and conditions for all fees and services in the cardholder agreement.

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 4 of 13

Instruction & Information D

All Fees

Amount

Details

Spend Money

Per purchase with PIN

$0

 

 

 

 

Per purchase with signature

$0

 

 

 

 

Get Cash in the U.S.

 

 

 

 

 

ATM withdrawal, in-network

$0

“In Network” refers to Bank of America ATMs. Locations can

 

 

be found at www.bankofamerica.com/eddcard. You will not be

 

 

charged a fee by Bank of America.

ATM withdrawal,

$1.00

You will be charged this fee after 2 free for each deposit. “Out of

out-of-network

 

Network” refers to all the ATMs outside of Bank of America ATMs.

 

 

You may also be charged a fee by the ATM operator even if you do

 

 

not complete a transaction.*

Bank teller cash withdrawal

$0

Available at financial institutions that accept Visa cards. Limited to

 

 

available balance only.

Emergency cash transfer,

$15.00

All emergency cash transfers must be initiated through the Prepaid

domestic

 

Debit Card Customer Service Center.

Information

 

 

 

 

 

Customer service

$0

 

 

 

 

Online account information

$0

 

 

 

 

Account alert service

$0

 

 

 

 

ATM balance inquiry

$0

 

 

 

 

Using your card outside the U.S.

 

 

 

 

Each international

2%

Of total U.S. Dollar amount of transaction

transaction

 

 

International ATM

$1.00

This is the Bank of America fee. You may also be charged a fee by

withdrawal

 

the ATM operator, even if you do not complete a transaction.

Other

 

 

 

 

 

Online funds transfer

$0

 

 

 

 

Replacement card, domestic

$0

 

 

 

 

Replacement card, express

$10.00

Additional charge

delivery

 

 

Replacement card,

$10.00

Additional charge

international

 

 

Inactive account

$0

 

 

 

 

*ATM owners may impose an additional “convenience fee” or “surcharge fee” for certain ATM transactions (a sign should be posted at the ATM to indicate additional fees); however you will not be charged any additional convenience fee or surcharge fee at a Bank of America ATM. A Bank of America ATM means an ATM that prominently displays the Bank of America name and logo.

Your funds are eligible for FDIC insurance. Your funds are insured up to $250,000 by the FDIC in the event Bank of America, N.A. fails, if specific deposit insurance requirements are met. See fdic.gov/deposit/deposits/prepaid.html for details.

No overdraft/credit feature.

Contact Bank of America by calling 1.866.692.9374, 1.866.656.5913 (TTY), or 1.423.262.1650 (Collect, when calling outside the U.S.), by mail at Bank of America, PO Box 8488, Gray, TN 37615-8488, or visit www.bankofamerica.com/eddcard.

For general information about prepaid accounts, visit cfpb.gov/prepaid.

If you have a complaint about a prepaid account, call the Consumer Financial Protection Bureau at 1-855-411-2372 or visit cfpb.gov/complaint.

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 5 of 13

Instruction & Information E

FEDERAL PRIVACY ACT. The EDD requires disclosure of Social Security numbers to comply with California Unemployment Insurance Code, sections 1253 and 2627; with California Code of Regulations, Title 22, sections 1085, 1088, and 1326; with Code of Federal Regulations, Title 20, Part 604; and with U.S. Code, Title 8, sections 1621, 1641, and 1642.

INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information from individuals:

Agency Name:

Employment Development Department (EDD)

Title of Official Responsible for Information Maintenance:

Manager, EDD State Disability Insurance Office

Local Contact Person:

Contact Information:

Manager, EDD State Disability Insurance Office

You may contact State Disability Insurance by calling 1-800-480-3287. A list of

 

State Disability Insurance local office locations can be found on the Internet at

 

edd.ca.gov/disability/Contact_DI.htm. The address and phone number of State

 

Disability Insurance will also appear on the “Notice of Computation,” DE 429D,

 

issued at the time your benefit determination is made.

 

 

Maintenance of the information is authorized by:

California Unemployment Insurance Code, sections 2601 through 3272.

California Code of Regulations, Title 22, sections 2706-1, 2706-3, 2708-1, and 2710-1.

Consequences of not providing all or any part of the requested information:

Failure to supply any or all information may cause delay in issuing benefit payments or may cause you to be denied benefits to which you are entitled.

If you willfully make a false statement or representation or knowingly withhold a material fact to obtain or increase any benefit or payment, the EDD will disqualify you from receiving benefits and/or services and may initiate criminal prosecution against you.

Principal purpose(s) for which the information is to be used:

To determine eligibility for Disability Insurance benefits.

To be summarized and published in statistical form for the use and information of government agencies and the public (your name and identification will not appear in publications).

To be used to locate persons who are being sought for failure to provide child, spousal, or other court-ordered support.

To be used by other governmental agencies to determine eligibility for public social services under the provisions of California Welfare and Institutions Code, Division 9.

To be used by the EDD to carry out its responsibilities under the California Unemployment Insurance Code.

To be exchanged pursuant to California Unemployment Insurance Code, section 322, and California Civil Code, section 1798.24, with other governmental departments and agencies, both federal and state, which are concerned with any of the following:

(1)Administration of an Unemployment Insurance program.

(2)Collection of taxes which may be used to finance Unemployment Insurance or State Disability Insurance.

(3)Relief of unemployed or destitute individuals.

(4)Investigation of labor law violations or allegations of unlawful employment discrimination.

(5)The hearing of workers’ compensation appeals.

(6)Whenever necessary to permit a state agency to carry out its mandated responsibilities where the use to which the information will be put is compatible with the purpose for which it was gathered.

(7)When mandated by state or federal law. Disclosures under California Unemployment Insurance Code, section 322, will be made only in those instances in which it furthers the administration of the programs mandated by that Code.

Pursuant to California Unemployment Insurance Code, sections 1095 and 2714: (1) Information may be revealed to the extent necessary for the administration of public social services, to the Director of Social Services or his/her representatives, or to the Director of Child Support Services or his/her representatives; (2) Claimant identity may be released to the Department of Rehabilitation.

Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code, sections 1095 and 2714.

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 6 of 13

Instruction & Information F

SAMPLE, this page for reference only

Claim for Disability Insurance (DI) Benefits

Health Insurance Portability and Accountability Act (HIPAA) Authorization

Claimant Social Security Number 0 0 0 0 00 0 0 0

Claimant Name (First)

(MI) (Last)

S a m p l e

C l a i m a n t

I authorize

G e o f f B o o k e r

(Person/Organization providing the information) to furnish and disclose all my health information and to allow inspection of and provide copies of any medical, vocational rehabilitation, and billing records concerning my disability for which this claim is filed that are within their knowledge to the following employees of the California Employment Development Department (EDD): Disability Insurance Branch examiners, their direct supervisors/managers and any other EDD employee who may have a need to access this information in order to process my claim and/or determine eligibility for State Disability Insurance benefits.

I understand that EDD is not a health plan or health care provider, so the information released to EDD may no longer be protected by federal privacy regulations.

(45 CFR Section 164.508(c)(2)(iii)). EDD may disclose information as authorized by the California Unemployment Insurance Code.

I agree that photocopies of this authorization shall be as valid as the original.

I understand I have the right to revoke this authorization by sending written notification stopping this authorization to EDD, DI Branch MIC 29, PO Box 826880, Sacramento, CA 94280. The authorization will stop on the date my request is received. I understand that the consequences for my revoking this authorization may result in denial of further State Disability Insurance benefits.

I understand that, unless revoked by me in writing, this authorization is valid for fifteen years from the date received by EDD or the effective date of the claim, whichever is later. I understand that I may not revoke this authorization to avoid prosecution or to prevent EDD’s recovery of monies to which it is legally entitled.

I understand that I am signing this authorization voluntarily and that payment or eligibility for my benefits will be affected if I do not sign this authorization. The consequences for my refusal to sign this authorization may result in an incomplete claim form that cannot be processed for payment of State Disability Insurance benefits.

I understand I have the right to receive a copy of this authorization.

Claimant Signature (Do Not Print)

Date Signed

Sample Claimant

M

M D D Y Y Y Y

 

1 2 2 5 2 0 1 5

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 7 of 13

SAMPLE, this page for reference only

Your disability claim can also be filed online at www.edd.ca.gov

PLEASE PRINT WITH BLACK INK.

PART A - CLAIMANT’S STATEMENT

A1. YOUR SOCIAL SECURITY NUMBER

0 0 00 0 0 0 0 0

A2. IF YOU HAVE PREVIOUSLY BEEN ASSIGNED AN EDD CUSTOMER ACCOUNT NUMBER, ENTER THAT NUMBER HERE

N o

A3. CALIFORNIA DRIVER

A4. GENDER

LICENSE OR ID NUMBER

MALE FEMALE

Z 1 2 3 4 5 6 7

X

A5. IF YOU EVER USED OTHER SOCIAL SECURITY NUMBERS,

 

A6. STATE GOVERNMENT EMPLOYEE

A7. YOUR DATE OF BIRTH

ENTER THOSE NUMBERS BELOW

 

 

(IF “YES” INDICATE BARGAINING UNIT#)

 

 

 

 

 

 

YES X NO UNIT#

M

M D D Y Y Y Y

 

 

 

 

0 1 0 1 1 9 0 0

A8. YOUR LEGAL NAME

(FIRST)

(MI)

(LAST)

 

 

SUFFIX

S a m p l e

C l a i m a n t

A9. OTHER NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED

 

(FIRST)

(MI)

(LAST)

SUFFIX

(FIRST)

(MI)

(LAST)

SUFFIX

A10. YOUR HOME AREA CODE AND TELEPHONE NUMBER

9 9 9 0 2 3 6 7 8 9

A11. YOUR CELL AREA CODE AND TELEPHONE NUMBER

1 1 1 0 0 20 0 4 7

A12. LANGUAGE YOU PREFER TO USE

 

 

 

 

ENGLISH

SPANISH

CANTONESE

VIETNAMESE

ARMENIAN PUNJABI

TAGALOG

OTHER

X

A13. YOUR MAILING ADDRESS, PO BOX OR NUMBER/STREET/APARTMENT, SUITE, SPACE#, OR PMB# (PRIVATE MAIL BOX)

1 2 3 A n y S t r e e t

CITY

STATE

ZIP OR POSTAL CODE

COUNTRY (IF NOT U.S.A.)

A n y t o w n

C A 1 2 3 4 5

A14. YOUR RESIDENCE ADDRESS, REQUIRED IF DIFFERENT FROM YOUR MAILING ADDRESS

NUMBER/STREET/APARTMENT OR SPACE#

CITY

STATE

ZIP OR POSTAL CODE

COUNTRY (IF NOT U.S.A.)

A15. YOUR LAST OR CURRENT EMPLOYER - IF YOUR LAST OR CURRENT EMPLOYMENT WAS SELF-EMPLOYMENT, ENTER “SELF” AND FILL-IN THIS OPTION. NAME OF YOUR EMPLOYER [STATE GOVERNMENT EMPLOYEES: PROVIDE THE AGENCY NAME (FOR EXAMPLE: CALTRANS)]

SELF

R o a d r u n n e r P a s t r i e s

NUMBER/STREET/SUITE# (STATE GOVERNMENT EMPLOYEES: PLEASE PROVIDE THE ADDRESS OF YOUR PERSONNEL OFFICE)

6 4 7 A r m i s t i c e W a y

CITY

 

STATE ZIP OR POSTAL CODE

COUNTRY (IF NOT U.S.A.)

A n y w h e r e

C A 6 6 2 2 2

 

EMPLOYER’S TELEPHONE NUMBER

 

 

4 9 9

3 1 1 1 1 1 1

 

 

A16. AT ANY TIME DURING YOUR DISABILITY, WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT

AUTHORITIES BECAUSE YOU WERE CONVICTED OF

YES

X NO

VIOLATING A LAW OR ORDINANCE?

A17. BEFORE YOUR DISABILITY BEGAN, WHAT

WAS THE LAST DAY YOU WORKED?

1M 2M 0D 1D 2Y 0Y 1Y 5Y

A18. WHEN DID YOUR DISABILITY BEGIN?

1M 2M 1D 6D 2Y 0Y 1Y 5Y

A20. SINCE YOUR DISABILITY BEGAN, HAVE YOU WORKED OR ARE YOU WORKING ANY FULL OR PARTIAL DAYS?

YES

X NO

A19. DATE YOU WANT YOUR CLAIM TO BEGIN IF DIFFERENT THAN THE DATE ENTERED IN A18

M M D D Y Y Y Y

A21 A. IF YOU RECOVERED, ENTER DATE:

A21 B. IF YOU RETURNED TO WORK,

 

ENTER DATE:

M M D D Y Y Y Y

M M D D Y Y Y Y

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 8 of 13

SAMPLE, this page for reference only

PART A - CLAIMANT’S STATEMENT - CONTINUED

A22. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER

0

0

0

0

0

0

0

0

0

 

 

A23. WHAT IS YOUR REGULAR OR CUSTOMARY OCCUPATION?

P a s t r y C h e f

A24. WHY DID YOU STOP WORKING? (SELECT ONLY ONE BOX)

LAYOFF

UNPAID LEAVE OF ABSENCE

X ILLNESS, INJURY, OR PREGNANCY

VOLUNTARILY QUIT OR RETIRED

TERMINATED

OTHER REASON

A25. HOW WOULD YOU DESCRIBE OR CLASSIFY YOUR JOB?

X

Mostly sit; occasionally stand or walk; occasionally lift, carry, push, pull, or otherwise move objects that weigh 10 lbs. or less. Mostly walk/stand; occasionally lift, carry, push, pull, or otherwise move objects that weigh up to 20 lbs.

Constantly lift, carry, push, pull, or otherwise move objects that weigh up to 10 lbs.; frequently up to 20 lbs.; occasionally up to 50 lbs. Constantly lift, carry, push, pull, or otherwise move objects that weigh up to 20 lbs.; frequently up to 50 lbs.; occasionally up to 100 lbs.

Constantly lift, carry, push, pull, or otherwise move objects that weigh over 20 lbs.; frequently over 50 lbs.; occasionally over 100 lbs.

A26. IF YOUR EMPLOYER(S) CONTINUED OR WILL CONTINUE TO PAY YOU DURING YOUR DISABILITY, INDICATE

TYPE OF PAY:

Paid Time Off

 

 

 

 

 

 

SICK

VACATION

(PTO)

ANNUAL

OTHER (EXPLAIN)

A27. MAY WE DISCLOSE BENEFIT PAYMENT INFORMATION TO YOUR EMPLOYER(S)?

YESNO

A28. SECOND EMPLOYER NAME (IF YOU HAVE MORE THAN ONE EMPLOYER)

C o s m i c C o o k i e s

NUMBER/STREET/SUITE#

4 6 9 T h r i f t y W a y

CITY

STATE ZIP OR POSTAL CODE

 

 

COUNTRY (IF NOT U.S.A.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

l

u

e

b

e

l

l

 

 

 

 

 

 

 

 

C

A

 

8

4

3

6

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BEFORE YOUR DISABILITY BEGAN, WHAT WAS THE LAST DAY YOU WORKED FOR THIS EMPLOYER?

 

EMPLOYER’S TELEPHONE NUMBER

M

M

D

D

Y

Y

Y

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

1

6

2

0

1

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A29. IF YOU HAVE MORE THAN 2 EMPLOYERS CHECK HERE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A30. IF YOU ARE A RESIDENT OF AN ALCOHOLIC RECOVERY HOME OR A DRUG-FREE RESIDENTIAL FACILITY, PROVIDE THE FOLLOWING: NAME OF FACILITY

NUMBER/STREET/SUITE#

CITY

STATE

ZIP OR POSTAL CODE

AREA CODE AND TELEPHONE NUMBER

A31. HAVE YOU FILED OR DO YOU INTEND TO FILE FOR WORKERS’ COMPENSATION BENEFITS?

YES - COMPLETE ITEMS A32 THROUGH A38

NO - SKIP ITEMS A33 THROUGH A38

A32. WAS THIS DISABILITY CAUSED BY YOUR JOB?

YES

NO

A33. DATE(S) OF INJURY SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM

M M D D Y Y Y Y M M D D Y Y Y Y M M D D Y Y Y Y M M D D Y Y Y Y

A34. WORKERS’ COMPENSATION INSURANCE COMPANY NAME

 

 

 

 

 

 

AREA CODE AND TELEPHONE NUMBER

 

EXTENSION (IF ANY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER/STREET/SUITE#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

STATE

 

ZIP CODE

 

 

 

 

 

 

WORKERS’ COMPENSATION CLAIM NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DE 2501 Rev. 81 (3-20) (INTERNET)

Page 9 of 13

SAMPLE, this page for reference only

PART A - CLAIMANT’S STATEMENT - CONTINUED

A35. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER

 

0

 

 

 

 

 

 

0

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A36. WORKERS’ COMPENSATION ADJUSTER’S NAME

 

 

 

 

 

 

 

 

AREA CODE AND TELEPHONE NUMBER

EXTENSION (IF ANY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A37. EMPLOYER’S NAME SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM

AREA CODE AND TELEPHONE NUMBER

EXTENSION (IF ANY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A38. YOUR ATTORNEY’S NAME (IF ANY) FOR YOUR WORKERS’ COMPENSATION CASE

AREA CODE AND TELEPHONE NUMBER

EXTENSION (IF ANY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTORNEY’S ADDRESS NUMBER/STREET/SUITE#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORKERS’ COMPENSATION APPEALS

CITY

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

BOARD/ADJ CASE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A39. SELECT YOUR PREFERRED PAYMENT METHOD

oEDD DEBIT CARDSM oCHECK

 

 

 

 

 

A40. Declaration and Signature. By my signature on this claim statement, I claim benefits and certify that for the period covered by this claim I was unemployed and disabled. I understand that willfully making a false statement or concealing a material fact in order to obtain payment of benefits is a violation of California law and that such violation is punishable by imprisonment or fine or both. I declare under penalty of perjury that the foregoing statement, including any accompanying statements, is to the best of my knowledge and belief true, correct, and complete. By my signature on this claim statement, I authorize the California Department of Industrial Relations and my employer to furnish and disclose to State Disability Insurance all facts concerning my disability, wages or earnings, and benefit payments that are within their knowledge. By my signature on this claim statement, I authorize release and use of information as stated in the “Information Collection and Access” portion of this form (see Informational Instructions, page D). I agree that photocopies of this authorization shall be as valid as the original, and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of the claim, whichever is later.

CLAIMANT’S SIGNATURE (DO NOT PRINT) OR SIGNATURE MADE BY MARK (X)

Sample Claimant

DATE SIGNED

1M 2M 1D 6D 2Y 0Y 1Y 5Y

A41. IF YOUR SIGNATURE IS MADE BY MARK (X), CHECK THE BOX AND IT MUST BE ATTESTED BY TWO WITNESSES WITH THEIR ADDRESSES.

 

1st WITNESS SIGNATURE (PRINT AND SIGN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

M

D

D

Y

Y

Y

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER/STREET/APARTMENT OR SPACE#, PO BOX OR PRIVATE MAIL BOX ADDRESSES NOT ACCEPTABLE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2nd WITNESS SIGNATURE (PRINT AND SIGN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

M

D

D

Y

Y

Y

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER/STREET/APARTMENT OR SPACE#, PO BOX OR PRIVATE MAIL BOX ADDRESSES NOT ACCEPTABLE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A42.

 

 

 

CHECK THIS BOX IF YOU ARE THE PERSONAL REPRESENTATIVE SIGNING ON BEHALF OF CLAIMANT AND COMPLETE THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(MI)

 

(LAST)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

, REPRESENT THE CLAIMANT IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS MATTER AS AUTHORIZED BY

 

 

DECLARATION OF INDIVIDUAL CLAIMING DISABILITY INSURANCE BENEFITS DUE AN INCAPACITATED OR DECEASED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMANT, DE 2522 (SEE INSTRUCTION & INFORMATION A, UNDER HOW TO APPLY #4)

 

 

POWER OF ATTORNEY (ATTACH COPY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL REPRESENTATIVE’S SIGNATURE (DO NOT PRINT)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

M

D

D

Y

Y

Y

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DE 2501 Rev. 81 (3-20) (INTERNET)

Page 10 of 13

File Attributes

Fact Name Detail
Purpose The EDD DE 2501 form is used for filing a claim for state disability insurance (SDI) benefits in California.
Governing Law The form is governed by the California Unemployment Insurance Code.
Eligibility Applicants must have a medical certification from a healthcare provider and have earned a certain amount of wages in the base period to qualify.
Filing Method Claims can be submitted online through the EDD’s website or by mail using the paper form DE 2501.

How to Fill Out EDD DE 2501

Filling out the EDD DE 2501 form is a crucial step for individuals seeking to claim disability insurance benefits in certain situations. Despite its importance, navigating through the form’s requirements can feel daunting without guidance. However, with a clear, step-by-step approach, applicants can complete the form accurately and efficiently. Once submitted, the form will be reviewed by the relevant department, and the applicant will be provided with a decision regarding their disability insurance benefits. Remember, filling out this form accurately can significantly impact the processing time and outcome of your application.

  1. Start by gathering all necessary documentation related to your disability claim, including any medical certificates, employment information, and personal identification.
  2. Enter your personal information in the designated sections of the form. This includes your full name, social security number, date of birth, and contact details. Ensure all information is accurate and matches your identification documents.
  3. Provide detailed employment information as requested in the form. This should include your employer’s name, address, your job title, and the last day you worked before your disability began.
  4. In the section concerning your medical condition, describe the nature of your disability. Include specific details about your diagnosis, the date of onset, and how it affects your ability to work.
  5. Indicate your preferred method for receiving benefits. Options usually include direct deposit into a bank account or receiving a check by mail. If you choose direct deposit, ensure you provide accurate banking details, including your account number and routing number.
  6. If applicable, specify any other income you are receiving or expect to receive while your claim is being processed. This includes things like paid time off, workers' compensation, or other benefits.
  7. Date and sign the form to certify that the information provided is true and complete to the best of your knowledge. Falsification of details can lead to repercussions, including the denial of benefits.
  8. Review your application thoroughly. Before submitting, ensure that all sections are filled out and no required information is missing. Incomplete forms can delay the processing of your claim.
  9. Submit the completed form to the address or online portal provided by the Employment Development Department (EDD). Make sure to follow any additional submission instructions provided by EDD.

After submitting the form, the waiting period for an initial decision varies. During this time, it’s important to respond promptly to any requests for additional information or documentation. The outcome of your application will be communicated to you through the contact information provided. Successfully navigating this process is a positive step toward securing the support you need during your period of disability.

Frequently Asked Questions

What is the EDD DE 2501 form?

The EDD DE 2501 form, issued by the California Employment Development Department (EDD), is used to file for State Disability Insurance (SDI) benefits. These benefits offer short-term compensation to eligible workers who are unable to perform their regular or customary work due to a physical or mental disability, including pregnancy or childbirth.

Who needs to fill out the EDD DE 2501 form?

This form needs to be filled out by individuals who are seeking to claim State Disability Insurance benefits. It's important for employees who have experienced a non-work-related illness, injury, pregnancy, or childbirth, and who are unable to earn their regular wages due to these conditions.

Where can I obtain the EDD DE 2501 form?

You can obtain the EDD DE 2501 form in several ways:

  • Download a PDF version from the California EDD website.
  • Request a paper form by mail through the EDD's automated phone system.
  • Visit a local EDD office to pick up a copy in person.

What information do I need to provide on the EDD DE 2501 form?

When filling out the form, you'll be required to provide detailed information regarding:

  • Your personal and contact information.
  • Your employment history and details about your wages.
  • The specific reason for your disability claim.
  • Medical information related to your disability, as certified by a healthcare provider.
Complete and accurate information is crucial for the processing of your claim.

How do I submit the EDD DE 2501 form?

After completing the form, you can submit it through one of the following ways:

  1. Mail the completed form to the EDD address provided on the form.
  2. Submit it in person at a local EDD office.
  3. Some circumstances may allow for online submission through the EDD’s website, depending on specific qualifications and requirements.
Ensure to check the latest submission guidelines on the EDD website.

When should the EDD DE 2501 form be submitted?

It is recommended to submit the form as soon as possible after the first day you become disabled and unable to work. There is a 49-day deadline from the date your disability begins to file your claim. Submitting the form beyond this deadline may result in a loss of benefits or a delay.

Can I file for EDD DE 2501 online?

Yes, in many cases, you can file for disability benefits online through the California EDD website. This method is often faster and more convenient than mailing a paper form. However, eligibility to file online can vary, so it’s important to verify your eligibility for online submission on the EDD website.

How long does it take to process the EDD DE 2501 form?

The processing time for the EDD DE 2501 form can vary depending on the current volume of claims and the completeness of your application. Generally, it takes about 14 days from the time the EDD receives your claim to process it. If additional information or documentation is required, this could extend the processing time.

What should I do if my EDD DE 2501 claim is denied?

If your claim for State Disability Insurance benefits is denied, you have the right to appeal the decision. The EDD will provide instructions on how to file an appeal, which typically includes submitting a written appeal form within 30 days of receiving your denial notice. It's important to provide any additional information or documentation that could support your claim during the appeal process.

Common mistakes

Filling out the EDD DE 2501 form can be a challenging process for many. One common mistake is not providing complete information. People often overlook sections or provide partial answers thinking they are not relevant. This can delay the processing of the form, as the department needs all the requested details to proceed with your disability claim.

Another issue often encountered is inaccurately reporting income. It's crucial to report all sources of income correctly. Failure to do so not only impacts the accuracy of your claim but could also lead to penalties or a denial of your claim. Taking the time to double-check income reporting can save a lot of trouble later on.

Many individuals also forget to sign and date the form before submitting it. This oversight might seem minor but is actually critical. An unsigned form is considered incomplete and cannot be processed. Ensuring that the form is signed is a simple yet essential step in the submission process.

Not attaching required documentation is another common pitfall. Supporting documents, such as medical certifications or proof of income, are vital for your claim to be validated. Missing documents can cause significant delays or even result in the denial of your claim.

There’s also a tendency to use incorrect codes or provide insufficient medical information. The medical details and codes help the department understand your situation better and assess your claim accurately. Providing vague or incorrect information might lead to misunderstandings or requests for additional information, slowing down the process.

A frequent mistake is not checking the form for errors before submission. Typos, incorrect dates, or other errors can complicate your claim. It's advisable to thoroughly review the form or even have someone else check it to ensure accuracy.

Some individuals fail to update their contact information, leading to missed communications about their claim. If the department cannot reach you, it might delay the process or result in a decision made with incomplete information.

Last but not least, submitting the form too late is a mistake many make. There are strict deadlines for filing a disability claim. Missing these deadlines can result in a loss of benefits. Keeping track of timelines and submitting early can help avoid this issue.

Documents used along the form

When you're dealing with the EDD DE 2501 form, which is used to claim for State Disability Insurance (SDI) benefits in California, it's not unusual to need a few other forms and documents to successfully navigate your claim. These documents support your application, ensuring that all your bases are covered and making the process smoother. Here's a rundown of some of the other essential forms and documents often required alongside the EDD DE 2501 form.

  • Doctor's Certification - This is a necessary document where your healthcare provider certifies your disability, detailing the condition and the expected duration of your inability to work.
  • EDD DE 2501F - Similar to the EDD DE 2501, this form is specifically for Paid Family Leave (PFL) claims, where an individual needs to take time off to care for a seriously ill family member or bond with a new child.
  • Proof of Employment - Often, you'll need to provide your most recent pay stubs or an employment verification letter to prove your employment status and income level pre-disability.
  • Identity Verification - A copy of a valid ID, such as a driver's license or passport, may be required to verify your identity as part of the process.
  • Previous Year's Tax Return - For self-employed individuals, your tax return can be necessary to demonstrate your earnings and work history.
  • Bank Statements - Sometimes, recent bank statements are requested to verify your financial situation, particularly if you're applying for advanced or additional benefits.
  • EDD DE 2525XX - This is a form requesting a physician's supplementary certification that may be necessary if your disability extends beyond the originally estimated recovery date.
  • Authorization for Release of Medical Information - This form allows your healthcare provider to share your medical records with the EDD to support your disability claim.
  • Direct Deposit Form - If you prefer to receive your SDI benefits via direct deposit, completing this form will allow the EDD to deposit funds directly into your bank account.

Each of these documents plays a pivotal role in the SDI benefits claim process, serving to substantiate your claim, verify your identity, and streamline benefit payments. While it may seem like a lot of paperwork, getting everything in order can significantly expedite your claim's processing time, helping you receive your benefits faster. Remember, the goal is to provide a thorough and accurate picture of your situation to ensure that your benefits reflect your needs appropriately.

Similar forms

The EDD DE 2501 form, used for filing for Disability Insurance (DI) benefits in California, shares similarities with the FMLA (Family and Medical Leave Act) Certification form. Both are designed to provide benefits or protected leave to employees under certain medical or family-related conditions. While the EDD DE 2501 form is specifically for state disability benefits, the FMLA Certification form is used to validate the need for family or medical leave under federal law, ensuring job protection during the leave period.

Another similar document is the Short-Term Disability (STD) claim form that many private insurance companies use. Like the EDD DE 2501, the STD form is filled out when an employee cannot work due to a temporary medical condition. Both forms require detailed medical information to prove the disability claim. However, the STD claim form pertains to private insurance benefits, whereas the EDD DE 2501 relates to state-funded disability insurance.

The Workers' Compensation First Report of Injury or Illness form is also comparable. It is used when an employee gets injured on the job or develops a work-related illness. Both this form and the EDD DE 2501 collect information about the nature of the injury or illness, though the Workers' Compensation form is specifically for incidents occurring in the workplace and aims to cover medical expenses and wage loss through employer-provided workers' compensation insurance.

The SSA-16 form, or Application for Social Security Disability Insurance (SSDI), has parallels with the EDD DE 2501 form too. Both are governmental forms designed to assist individuals who are unable to work due to disability. While the SSA-16 applies to a federal program providing long-term assistance, the EDD DE 2501 targets short-term state-level disability benefits in California, marking a difference in their respective durations and scopes of coverage.

The Paid Family Leave (PFL) claim form in California also shares aspects with the EDD DE 2501 form. Each serves to provide financial assistance under specific circumstances – the PFL for bonding with a new child or caring for a seriously ill family member, and the DE 2501 for the claimant's own disability. Although their purposes differ, both require proof of the claim and offer benefits funded by the California Employment Development Department.

Lastly, the Unemployment Insurance (UI) claim form, used when someone loses their job through no fault of their own and seeks temporary financial assistance, relates to the EDD DE 2501. While focusing on differing circumstances – unemployment versus disability – both forms are integral to accessing benefits provided by the state's Employment Development Department. Each requires personal and eligibility information to process and approve claims for state-funded assistance.

Dos and Don'ts

Applying for disability benefits can be a challenging process, and the EDD DE 2501 form is an essential step in requesting support from the State of California. To assist you in navigating this process smoothly, here's a list of do's and don'ts:

  • Do read the entire form and instructions carefully before you start. Understanding all the requirements will help ensure you complete the form correctly.
  • Do gather all the necessary information, such as your medical information and employment history, before beginning to fill out the form. This preparation can save you time and prevent delays.
  • Do use black ink if you are filling out the form by hand. Black ink is easier to read, making the review process faster.
  • Do be as accurate and detailed as possible when describing your medical condition. Detailed information helps the evaluators understand your situation better.
  • Do make a copy of the completed form for your records before submitting it. Keeping a copy can be helpful if there are any questions or issues later on.
  • Don't leave any sections blank. If a section does not apply to you, write "N/A" (not applicable) to indicate that you did not overlook it.
  • Don't guess on dates or other information. If you're unsure, take the time to verify the information before submitting the form.
  • Don't ignore the deadline for submitting the form. Late submissions can delay or even disqualify your claim.
  • Don't hesitate to ask for help if you find the form confusing. You may contact the EDD directly, or consider seeking assistance from a professional who is experienced with the process.

Misconceptions

The EDD DE 2501 form, required for claiming Disability Insurance benefits in California, is often misunderstood. Here are nine common misconceptions about the form and accurate information to dispel these myths.

  • Filing Online Is Not an Option: Many people believe they cannot submit the EDD DE 2501 form online, but in fact, California provides an online portal for this purpose, making the process more accessible.

  • Any Doctor Can Sign Your Form: It's assumed that any healthcare provider can sign off on the EDD DE 2501 form. However, only licensed physicians or practitioners within the United States who meet specific criteria are authorized to certify the claim.

  • There Is No Deadline for Submission: Contrary to popular belief, there is a strict timeframe for submitting the DE 2501 form to avoid delays or denials. Claims must be filed within 49 days of the date your disability begins.

  • You Can’t Work at All While Receiving Benefits: Many think receiving disability benefits means you cannot engage in any work. However, the EDD allows recipients to work part-time or perform limited duties, provided it does not exceed certain thresholds and is reported.

  • Benefits Are Tax-Free: It's a common misconception that disability benefits are not taxable. In reality, while California state does not tax these benefits, they are subject to federal tax if combined with other sources of income reaching a certain limit.

  • Submitting the DE 2501 Form Guarantees Benefits: Simply submitting the form does not ensure you will receive disability benefits. The EDD reviews each application thoroughly to ensure it meets eligibility criteria before approving claims.

  • Only Physical Health Issues Qualify: Many believe that only physical disabilities are covered. Mental and emotional illnesses that prevent a person from working can also qualify for benefits, provided they are certified by a healthcare professional.

  • The Form Must Be Filled Out in One Sitting: The assumption that you need to complete the DE 2501 form in one session is incorrect. If applying online, you can save your progress and return to it at a later date if needed.

  • Personal Assistance Is Not Available: Lastly, some think they are entirely on their own when filling out the form. The EDD provides assistance through its website, call centers, and local offices to help answer questions and guide claimants through the process.

It’s important to understand these aspects of the DE 2501 form to ensure a smoother process when applying for disability benefits. Clearing up these misconceptions can help applicants avoid unnecessary complications.

Key takeaways

Filing for Disability Insurance (DI) benefits in the state requires careful attention to detail and an understanding of the process to ensure accurate and timely support. The EDD DE 2501 form, a crucial document in this journey, serves as the initial claim form for individuals seeking these benefits. Here are key takeaways to consider when filling out and using this form:

  • Accuracy is Paramount: Providing accurate and complete information on the EDD DE 2501 form is vital. Errors or omissions can lead to delays in processing the claim or even result in denial of benefits. Double-check personal information, dates, and employment details before submission.
  • Timeliness Matters: There is a window during which you must file the DE 2501 form after becoming disabled. Filing the claim in a timely manner is crucial to avoid forfeiture of benefits. It is recommended to submit the form as soon as possible within the allowable time frame to ensure benefits are received when needed.
  • Supporting Documentation: Along with the DE 2501 form, claimants may be required to submit additional documentation to support their claim. This can include medical certification from a healthcare provider, proof of wages, and any other documents that verify the disability and entitlement to benefits. Preparing these documents in advance can expedite the process.
  • Utilize Available Resources: Navigating the claims process can be complex. Utilize resources offered by the Employment Development Department (EDD), including detailed instructions for completing the form, frequently asked questions, and customer service support. These resources can provide guidance and clarify any uncertainties surrounding the claims process.

Adherence to these guidelines can streamline the process of claiming Disability Insurance benefits, ensuring that individuals receive the support they need with as little delay as possible. It is essential for claimants to approach this process with care and attention to detail, leveraging the resources available to them for assistance.

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