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.