Fillable Printable Report Of Voluntary Plan Disability Claim (De 2523)

Report Of Voluntary Plan Disability Claim (De 2523)

DE 2523 Rev. 20 (8-17) (INTERNET) Page 1 of 2

REPORT OF V O LUNTARY PLAN DISABILITY CLAIM

PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM. TO REPORT A V OL UNTARY PLAN FAMILY LEAVE

(VPFL) CLAIM, YOU MUST SUBMIT A COMPLETE D RE P ORT OF VOLUNTARY PLAN FAMILY LEAVE CLAIM (DE 2523F).

A. CLAIMANT INFORMATION

WITHIN 15 DAYS AFTER RECEIPT OF A FIRST CLAIM FOR DISABILITY BENEFITS, COMPLETE ITEMS 1 – 14 AND SUBMIT.

(RETAIN A COPY OF COMPLETED SECTION A*)

1. CLAIMANT’S NAME (FIRST, MIDDLE, LAST)

2. SOCIAL SECURITY

NUMBER

– –

DATE DISABILITY BEGAN

CLAIMANT’S MAILING ADDRESS

STREET/PO BOX

TELEPHONE NUMBER

– –

CITY

STATE

ZIP CODE

DATE OF BIRTH

/ /

MM DD YYYY

SEX

MALE FEMALE

VOLUNTARY PLAN EMPLOYER NAME

8. VOLUNTARY PLAN NUMBER

INTERNATIONAL CLASSIFICATION OF DISEASES (ICD) CODE

10. DIAGNOSIS

11. DO YOU WANT STATE AWARD INFORMATION? NO YES

IF YES, ENTER THE NAME AND ADDRESS ( INCLUDING ZIP CODE) OF EMPLOYER OR PLAN ADMINIS TRATOR

NAME:

ADDRESS:

12. (REQUIRED) TYPE OR PRINT NAME OF PERSON COMPLETING

SECTION A

13. TELEPHONE NUMBER

– –

14. DATE

FOR DEPARTMENT USE ONLY

CLAIM EFFECTIVE DATE

W EEKLY BENEFIT AMOUNT

MAXIMUM BENEFIT AMOUNT

B. WITHIN 35 DAYS AFTER FINAL PAYMENT FOR EACH PERIOD OF DISABILI TY (*ON RETAINED COPY),

COMPLETE ITEMS 15-22 AND SUBMIT.

15. NUMBER OF DAYS

BENEFITS PAID

16. BENEFI TS PAID THROUGH

17. TOTAL AMOUNT OF

BENEFITS PAID

18. TOTAL AMOUNT

DIVERTED TO

SATISFY SUPPORT

OBLIGATION

19. CLAIM STATUS (CHECK ALL APPROPRIATE BOXES)

BENEFITS EXHAUSTED BENEFITS NOT EXHAUSTED BENEFITS DENIED (ATTACH A

COPY OF DENIAL LETTER)

RECOVERED/RETURNED TO WORK

ADJUSTMENT

20. (REQUIRED) TYPE OR PRINT NAME OF PERSON COMPLETING

SECTION B

21. TELEPHONE NUMBER

– –

22. DATE

INSTRUCTIO NS F OR COMPLETING THE

REPORT OF VO L UNTARY PLAN DISABILITY CLAIM, DE 2523

Section A: Complete items 1-14 and return within 15 days after the receipt of a first claim for disability benefits.

Submit to address below. (Retain a copy of completed Section A.) California Code of Regulation s, Title 22,

Section 326 7-1.

1. Enter the claimant’s full name.

2. Enter all digits of the claimant’s social security number.

(A claim cannot be processed without an accurate number. The use of an incorrect number can result in erroneous notices to the

claimant and employer.)

3. Enter the date the disability began.

4. Enter the claimant’s current mailing address and tele pho ne number .

5. Enter the month, day, and year of claimant’s date of birth. (mm/dd/yyyy)

6. Enter a check mark in the appropriate box.

7. Enter the employer's name.

8. Enter the six digit voluntary plan number.

9. Enter International Classification of Diseases (ICD) C ode. [Published by the World Health Organization (WHO)].

10. Enter the physician’s diagnosis.

11. Enter an “X” in the appropriate box. If yes is checked, the EDD will mail the award information to the address provided.

12. Enter the printed name of the person completing Section A.

13. Enter the telephone number of the person completing Section A.

14. Enter the current date.

Sectio n B: On the retained copy of Section A, complete items 15-22 and return within 35 days after final

payment for each period of disability, California Code of Regulations, Title 22, Sect ion 326 7-1. Submit to

address below.

15. Enter the number of days disability benefits were paid.

(Includes days paid under a supplemental accident and sickness plan or salary continuance only if they are part of the

Voluntary Plan.)

16. Enter the last date for which disability benefits were paid.

17. Enter the amount of disability benefits paid.

(Enter the amount paid for the days entered in item 15. Include any amount withheld for support obligation.)

18. Enter the amount of disability benefits that were diverted to satisfy a support obligation.

(Enter the amount of benefits withheld under the Support Intercept Program. This amount must be included in the total of item 17.)

19. Enter an “X” in the boxes that apply to the current claim stat us.

Benefits Exhausted: The total maximum benefit amount paid.

Benefits Not Exhausted: A balance of the maximum benefit amount remains.

Benefits Denied: No benefits have been paid. A copy of the denial letter to the claimant must be electronically attached or

submitted under separate cover.

Recovered/R eturn to Work: The claimant has recovered from the disability and/or returned to work.

Adjustment: Use i f submitting an amended report.

20. Enter the printed name of the person completing Section B.

21. Enter the teleph one number of the person completing Section B.

22. Enter the current date.

INTERNET or HARDCOPY VERSION/SUBMIT COMPLETED FORM AS FOLLOWS:

MAIL TO:

FAX TO:

Employment Development Department

Voluntary Plan Unit

PO Box 120831

San Diego, CA 92112-0831

916-449-1922

DE 2523 Rev. 20 (8-17) (INTERNET) Page 2 of 2