Form DE2501 "Claim for Disability Insurance (Di) Benefits - Sample" - California

What Is DE 2501?

Form DE 2501, Claim for Disability Insurance (DI) Benefits, is a state of California form to request, by mail, worker-funded benefits to eligible workers who have a full or partial loss of wages due to disabilities that are not work-related. Note that your employer will be notified that you have submitted a DI claim, however, your detailed information is confidential and will not be shared with your employer. 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.

This form can not be used if you are insured by a voluntary plan or filing for non-industrial disabilities insurance benefits. Additionally, in order to be eligible, you must be unable to do your regular work for at least 8 days, must be employed or actively looking for work at the time you became disabled, have lost wages due to this disability, have earned at least $300 in wages during your base period, are under the care and treatment of a licensed physician, complete the claim form within 49 days of becoming disabled, and your physician must complete the medical certification of your disability.

This California Disability Form DE 2501 is issued by the Employment Development Department. The latest form was issued in April 2019. A printable DE 2501 Claim Form version is available for download below.

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Download Form DE2501 "Claim for Disability Insurance (Di) Benefits - Sample" - California

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Claim for Disability Insurance (DI) Benefits
250110161
Health Insurance Portability and Accountability Act (HIPAA) Authorization
Claimant Social Security Number
Claimant Name
(First)
(MI)
(Last)
I authorize
(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.
Date Signed
Claimant Signature (Do Not Print)
M
D
D
Y
Y
Y
Y
M
CU
DE 2501 Rev. 79 (10-16) (INTERNET)
Page 1 of 7
Claim for Disability Insurance (DI) Benefits
250110161
Health Insurance Portability and Accountability Act (HIPAA) Authorization
Claimant Social Security Number
Claimant Name
(First)
(MI)
(Last)
I authorize
(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.
Date Signed
Claimant Signature (Do Not Print)
M
D
D
Y
Y
Y
Y
M
CU
DE 2501 Rev. 79 (10-16) (INTERNET)
Page 1 of 7
Your disability claim can also be filed online at www.edd.ca.gov/
250110162
PLEASE PRINT WITH BLACK INK.
PART A - CLAIMANT’S STATEMENT
A1. YOUR SOCIAL SECURITY
A2. IF YOU HAVE PREVIOUSLY BEEN ASSIGNED AN EDD
A3. CALIFORNIA DRIVER
A4. GENDER
NUMBER
CUSTOMER ACCOUNT NUMBER, ENTER THAT NUMBER HERE
LICENSE OR ID NUMBER
MALE
FEMALE
A7. YOUR DATE OF BIRTH
A5. IF YOU EVER USED OTHER SOCIAL SECURITY NUMBERS,
A6. STATE GOVERNMENT EMPLOYEE
ENTER THOSE NUMBERS BELOW
(IF “YES” INDICATE BARGAINING UNIT#)
M
M
D
D
Y
Y
Y
Y
YES
NO
UNIT#
A8. YOUR LEGAL NAME
(FIRST)
(MI)
(LAST)
SUFFIX
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
A11. YOUR CELL AREA CODE AND TELEPHONE NUMBER
A12. LANGUAGE YOU PREFER TO USE
ENGLISH
SPANISH
CANTONESE
VIETNAMESE
ARMENIAN
PUNJABI
TAGALOG
OTHER
A13. YOUR MAILING ADDRESS, PO BOX OR NUMBER/STREET/APARTMENT, SUITE, SPACE#, OR PMB#
(PRIVATE MAIL BOX)
CITY
STATE
ZIP OR POSTAL CODE
COUNTRY
(IF NOT U.S.A.)
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.
SELF
NAME OF YOUR EMPLOYER
[STATE GOVERNMENT EMPLOYEES: PROVIDE THE AGENCY NAME (FOR EXAMPLE: CALTRANS)]
NUMBER/STREET/SUITE#
(STATE GOVERNMENT EMPLOYEES: PLEASE PROVIDE THE ADDRESS OF YOUR PERSONNEL OFFICE)
CITY
STATE
ZIP OR POSTAL CODE
COUNTRY
(IF NOT U.S.A.)
EMPLOYER’S TELEPHONE NUMBER
A17. BEFORE YOUR DISABILITY BEGAN, WHAT
A16. AT ANY TIME DURING YOUR DISABILITY, WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT
WAS THE LAST DAY YOU WORKED?
AUTHORITIES BECAUSE YOU WERE CONVICTED OF
YES
NO
VIOLATING A LAW OR ORDINANCE?
M
M
D
D
Y
Y
Y
Y
A18. WHEN DID YOUR DISABILITY BEGIN?
A19.
A18
DATE YOU WANT YOUR CLAIM TO BEGIN IF DIFFERENT THAN THE DATE ENTERED IN
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
A20
A21 A
A21 B
. SINCE YOUR DISABILITY BEGAN, HAVE YOU WORKED OR
. IF YOU RECOVERED, ENTER DATE:
. IF YOU RETURNED TO WORK,
ARE YOU WORKING ANY FULL OR PARTIAL DAYS?
ENTER DATE:
YES
NO
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
DE 2501 Rev. 79 (10-16) (INTERNET)
Page 2 of 7
250110163
PART A - CLAIMANT’S STATEMENT - CONTINUED
A22. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER
A23. WHAT IS YOUR REGULAR OR CUSTOMARY OCCUPATION?
A24. WHY DID YOU STOP WORKING?
ILLNESS, INJURY, OR PREGNANCY
(SELECT ONLY ONE BOX)
LAYOFF
UNPAID LEAVE OF ABSENCE
VOLUNTARILY QUIT OR RETIRED
TERMINATED
OTHER REASON
A25. HOW WOULD YOU DESCRIBE OR CLASSIFY YOUR JOB?
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
A27. MAY WE DISCLOSE BENEFIT PAYMENT
TYPE OF PAY:
INFORMATION TO YOUR EMPLOYER(S)?
Paid Time Off
YES
NO
SICK
VACATION
(PTO)
ANNUAL
OTHER
(EXPLAIN)
A28. SECOND EMPLOYER NAME
(IF YOU HAVE MORE THAN ONE EMPLOYER)
NUMBER/STREET/SUITE#
CITY
STATE
ZIP OR POSTAL CODE
COUNTRY
(IF NOT U.S.A.)
BEFORE YOUR DISABILITY BEGAN, WHAT WAS THE LAST DAY YOU WORKED FOR THIS EMPLOYER?
EMPLOYER’S TELEPHONE NUMBER
M
D
D
Y
Y
Y
Y
M
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?
A32. WAS THIS DISABILITY CAUSED BY YOUR JOB?
YES - COMPLETE ITEMS A32 THROUGH A38
NO - SKIP ITEMS A33 THROUGH A38
YES
NO
A33. DATE(S) OF INJURY SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM
M
D
D
Y
Y
Y
Y
M
D
D
Y
Y
Y
Y
M
D
D
Y
Y
Y
Y
M
D
D
Y
Y
Y
Y
M
M
M
M
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. 79 (10-16) (INTERNET)
Page 3 of 7
250110164
PART A - CLAIMANT’S STATEMENT - CONTINUED
A35. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER
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
FOR YOUR WORKERS’ COMPENSATION CASE
AREA CODE AND TELEPHONE NUMBER
EXTENSION
(IF ANY)
(IF ANY)
ATTORNEY’S ADDRESS NUMBER/STREET/SUITE#
WORKERS’ COMPENSATION APPEALS
CITY
STATE
ZIP CODE
BOARD/ADJ CASE NUMBER
PLEASE REVIEW, SIGN, AND DATE ITEM A39, AND IF APPLICABLE, ITEMS A40 AND A41
A
39. 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)
DATE SIGNED
M
M
D
D
Y
Y
Y
Y
A40. IF YOUR SIGNATURE IS MADE BY MARK (X), CHECK THE BOX AND IT MUST BE ATTESTED BY TWO WITNESSES WITH THEIR ADDRESSES.
DATE SIGNED
1st
WITNESS SIGNATURE
(PRINT AND SIGN)
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
DATE SIGNED
2nd WITNESS SIGNATURE
(PRINT AND SIGN)
Y
Y
M
M
D
D
Y
Y
NUMBER/STREET/APARTMENT OR SPACE#, PO BOX OR PRIVATE MAIL BOX ADDRESSES NOT ACCEPTABLE.
CITY
STATE
ZIP CODE
A41.
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
POWER OF ATTORNEY
(SEE INSTRUCTION & INFORMATION A, UNDER HOW TO APPLY #4)
(ATTACH COPY)
DATE SIGNED
PERSONAL REPRESENTATIVE’S SIGNATURE
(DO NOT PRINT)
M
M
D
D
Y
Y
Y
Y
DE 2501 Rev. 79 (10-16) (INTERNET)
Page 4 of 7
Claim for Disability Insurance (DI) Benefits -
Physician/Practitioner’s Certificate
250110165
PLEASE PRINT WITH BLACK INK.
PART B - PHYSICIAN/PRACTITIONER’S CERTIFICATE
B1. PATIENT’S SOCIAL SECURITY NUMBER
B2. PATIENT’S FILE NUMBER
B3. IF YOU KNOW THE PATIENT’S ELECTRONIC RECEIPT NUMBER, ENTER IT HERE:
B4. PATIENT’S DATE OF BIRTH
R
M
M
D
D
Y
Y
Y
Y
B5. PATIENT’S NAME
(FIRST)
(MI)
(LAST)
B7. STATE OR COUNTRY (IF NOT U.S.A.) THAT ISSUED LICENSE NUMBER ENTERED IN B6
B6. PHYSICIAN/PRACTITIONER’S LICENSE NUMBER
STATE
COUNTRY
B8. PHYSICIAN/PRACTITIONER LICENSE TYPE
B9. SPECIALTY
(IF ANY)
B10. PHYSICIAN/PRACTITIONER’S NAME AS SHOWN ON LICENSE
(FIRST)
(MI)
(LAST)
SUFFIX
B11. PHYSICIAN/PRACTITIONER’S ADDRESS
MAILING ADDRESS, PO BOX OR NUMBER/STREET/SUITE#
CITY
STATE
ZIP OR POSTAL CODE
COUNTRY
(IF NOT U.S.A.)
COUNTY HOSPITAL/GOVERNMENT FACILITY ADDRESS
FACILITY NAME
(IF APPLICABLE)
FACILITY ADDRESS, NUMBER/STREET/SUITE#
CITY
STATE
ZIP OR POSTAL CODE
COUNTRY
(IF NOT U.S.A.)
B12. THIS PATIENT HAS BEEN UNDER MY CARE AND TREATMENT FOR THIS MEDICAL PROBLEM
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
CHECK HERE TO INDICATE YOU ARE STILL TREATING THE PATIENT
FROM
M
TO
AT INTERVALS OF:
DAILY
WEEKLY
MONTHLY
AS NEEDED
OTHER
B13. AT ANY TIME DURING YOUR ATTENDANCE FOR THIS MEDICAL PROBLEM, HAS THE PATIENT BEEN INCAPABLE OF PERFORMING HIS/HER REGULAR
OR CUSTOMARY WORK?
M
D
D
Y
Y
Y
Y
YES - ENTER DATE DISABILITY BEGAN
M
NO - SKIP TO B33
WAS THE DISABILITY CAUSED BY AN ACCIDENT OR TRAUMA?
YES
NO
M
D
D
Y
Y
Y
Y
M
IF YES, INDICATE THE DATE THE ACCIDENT OR TRAUMA OCCURRED.
B14. DATE YOU RELEASED OR ANTICIPATE RELEASING PATIENT TO RETURN TO HIS/HER REGULAR OR CUSTOMARY WORK
(“UNKNOWN”, “INDEFINITE”, ETC., NOT ACCEPTABLE.)
M
D
D
Y
Y
Y
Y
M
CHECK HERE TO INDICATE PATIENT’S DISABILITY IS PERMANENT AND YOU NEVER ANTICIPATE RELEASING PATIENT TO RETURN TO HIS/HER
REGULAR OR CUSTOMARY WORK
B15. IF PATIENT IS NOW PREGNANT OR HAS BEEN PREGNANT, PLEASE CHECK THE APPROPRIATE BOX AND ENTER THE FOLLOWING:
ESTIMATED DELIVERY DATE:
M
D
D
Y
Y
Y
Y
DATE PREGNANCY ENDED:
M
D
D
Y
Y
Y
Y
M
M
TYPE OF DELIVERY, IF PATIENT HAS DELIVERED:
VAGINAL
CESAREAN
DE 2501 Rev. 79 (10-16) (INTERNET)
Page 5 of 7
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How to Fill out Form DE 2501?

Follow these DE 2501 Form instructions below. 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, or you may lose benefits.

  1. Gather the required information. You must make sure to provide the following information: first and last name, social security number, California Driver License number, most current employer's business name, phone number, and mailing address (as stated on your W-2 or paystub), last date you worked your regular duties and hours or date you began working at less than full duty or modified duty. Provide the following information on the form only if it applies to you: any wages you received or expect to receive from your employer, any workers' compensation claim information, if applicable, and provide the name, address, and phone number of any in-patient treatment at an alcoholic recovery home or drug-free facility.
  2. Complete the HIPAA Authorization and Part A - Claimant's Statement (pages 1-4), of the DE 2501 form. Write clearly in the spaces provided, use black ink only, and sign the form where indicated.
  3. After completing Part A, contact your physician/practitioner about completing, signing, and submitting your medical certification (Part B - Physician/Practitioner's Certificate, pages 5-7). You are responsible for obtaining a Physician/Practitioner Certification for your disability. Talk to your physician/practitioner about their process for submitting a DI claim. They do not all follow the same process. Some offices may have you mail in Part B, while others may mail in Part B themselves.

Where to Mail Form DE 2501?

To submit the claim, attach a postage stamp to a pre-addressed envelope and mail the completed paper claim form to:

State of California Employment Development Department

PO Box 989777

West Sacramento, CA 95798-9777

If you are not eligible for benefits, a Notice of Determination (DE 2517) will subsequently be mailed to you. You must meet eligibility requirements to receive benefits. If you are disqualified from receiving benefits, you will receive an Appeal Form (DE 1000A) with your disqualification notice. You have the right to appeal any decision, in writing, within 30 days of the mailing date of the disqualification notice.

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