Fillable Printable Claim For Disability Insurance (Di) Benefits (De 2501 Jacket)
Fillable Printable Claim For Disability Insurance (Di) Benefits (De 2501 Jacket)
Claim For Disability Insurance (Di) Benefits (De 2501 Jacket)
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 www.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 https://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 A39. 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.
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.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT. Federal law requires that we obtain a separate authorization and
signature that permits your physician/practitioner to provide medical information regarding your claim. The EDD collects medical and
health information in accordance with Code of Federal Regulations, Title 45, Part 164.
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:
Manager, EDD State Disability Insurance Office
Contact Information:
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
www.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. 79 (10-16)
(INTERNET)
Instruction & Information ADE 2501 Rev. 79 (10-16) Instruction & Information D
Page 1 of 4
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 “Practitioner’s
Certificate,” 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.
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 meet all requirements, the SDI
program will issue a secure EDD Debit Card and electronic
benefit payments which can be accessed using the debit card.
The majority of claims are processed and payments 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, either 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 and disabled 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,” DE 2525XX, 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 2525XXA,
(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 www.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 www.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. 79 (10-16) Instruction & Information CInstruction & Information B
DE 2501 Rev. 79 (10-16) (INTERNET)
Page
2 of 4
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 “Practitioner’s
Certificate,” 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.
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 meet all requirements, the SDI
program will issue a secure EDD Debit Card and electronic
benefit payments which can be accessed using the debit card.
The majority of claims are processed and payments 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, either 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 and disabled 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,” DE 2525XX, 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 2525XXA,
(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 www.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 www.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.
Instruction & Information CDE 2501 Rev. 79 (10-16) Instruction & Information B
DE 2501 Rev. 79 (10-16) (INTERNET)
Page 3 of 4
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 www.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 https://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 A39. 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.
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.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT. Federal law requires that we obtain a separate authorization and
signature that permits your physician/practitioner to provide medical information regarding your claim. The EDD collects medical and
health information in accordance with Code of Federal Regulations, Title 45, Part 164.
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:
Manager, EDD State Disability Insurance Office
Contact Information:
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
www.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. 79 (10-16) Instruction & Information AInstruction & Information D
DE 2501 Rev. 79 (10-16) (INTERNET)
Page
4 of 4