Fillable Printable De 1858
Fillable Printable De 1858
De 1858
THIS EMPLOYER IS REGISTERED UNDER THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE AND IS REPORTING WAGE
CREDITS THAT ARE BEING ACCUMULATED FOR YOU TO BE USED AS A BASIS FOR:
When you are unable to work or reduce your work hours because
of sickness, injury, or pregnancy, you may be eligible to receive
Disability Insurance (DI) benefi ts.
Your employer must provide a copy of “Disability Insurance
Provisions,” DE 2515, to each newly hired employee and to each
employee leaving work due to pregnancy or due to sickness or injury
that is not related to his/her job.
Claim Forms
• If your employer operates an approved voluntary plan in place
of disability insurance and you have chosen to be covered by it,
obtain DI claim forms from your employer.
• If you are not covered by a voluntary plan, obtain claim forms
from your doctor, hospital, or directly from any California Disability
Insurance (DI) Claim Management offi ce.
• File your “Claim for DI Benefi ts,” DE 2501, within 49 days of the fi rst
day of your disability to avoid losing benefi ts.
Paid Family Leave (PFL)
(funded entirely by employees’ contributions)
When you stop working or reduce your work hours to care for a family
member who is seriously ill or to bond with a new child, you may be
eligible to receive Paid Family Leave (PFL) benefi ts.
Your employer must provide a copy of “Paid Family Leave Program
Brochure,” DE 2511, to each newly hired employee and to each
employee leaving work to care for a seriously ill family member or to
bond with a new child.
Claim Forms
• If your employer operates an approved voluntary plan in place
of disability insurance and you have chosen to be covered by it,
obtain PFL claim forms from your employer.
• If you are not covered by a voluntary plan, obtain claim forms from
any California Disability Insurance (DI) Claim Management offi ce
or the PFL offi ce.
• File your “Claim for PFL Benefi ts,” DE 2501F, within 49 days of the
fi rst day of your family leave to avoid losing benefi ts.
FOR MORE INFORMATION ABOUT DI, VISIT THE EDD WEB SITE AT www.edd.ca.gov OR CALL 1-800-480-3287.
TTY (FOR DEAF OR HEARING-IMPAIRED INDIVIDUALS ONLY) IS AVAILABLE AT 1-800-563-2441.
FOR MORE INFORMATION ABOUT PFL, VISIT THE EDD WEB SITE AT
www.edd.ca.gov OR CALL 1-877-238-4373.
TTY (FOR DEAF OR HEARING-IMPAIRED INDIVIDUALS ONLY) IS AVAILABLE AT 1-800-445-1312.
STATE GOVERNMENT EMPLOYEES SHOULD CALL 1-866-352-7675 FOR DI AND 1-877-945-4747 FOR PFL.
Disability Insurance (DI)
(funded entirely by employees’ contributions)
DE 1858 Rev. 4 (11-08) (INTERNET) Page 1 of 1 GA 888/CU
