Fill in a Valid EDD DE 2501 Template

California’s disability program provides up to 52 weeks of benefit payments.

If you’re not able to do your regular work because of a disability, you may be eligible for benefits.

A disability includes:

•An illness or injury, either physical or mental.

•Surgery, including elective surgery.

•Pregnancy and childbirth.

When to Apply

You can apply nine days after you’re not able to do your regular work because of your disability. Apply within 49 days of this date to avoid losing benefits.

How to Complete Your Application

When completing your application:

•Use black ink only.

•Write clearly within the boxes provided.

•Enter your Social Security number on all pages of the application, including any attachments. If you do not have a Social Security number, you can leave the boxes blank.

How to Submit Your Application

Mail your completed application to us using the envelope provided. If your application is late, has errors, or is missing information, it could delay your claim or you could be denied benefits.

After we’ve received your application, including Part A and B, you’ll receive information by mail in about two weeks. The time it takes to process an application can vary. For faster processing, you can apply using SDI Online at edd.ca.gov/SDI_Online.

If you cannot complete your application because of your disability, or if you’re an authorized representative applying on behalf of an incapacitated or deceased person, call 1-800-480-3287 or send us a message using Ask EDD at askedd.edd.ca.gov.

The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.

Requests for services, aids, or alternate formats need to be made by calling 1 (866) 490-8879 (voice). TTY users, please call the California Relay Service at 711

The application has two parts.

For your application to be complete, we must receive Part A and Part B.

Part A –

Claimant’s Statement

You must complete and sign Part A.

•For question A13, if you have a private mailbox, include “PMB” at the beginning of the address.

•For help with questions A18 and A19, see “Your Benefit Amounts” on page 2. For A18, the first day you could not do your regular work is the date your disability began.

•If you have a work-related disability, complete questions A31 to A38. If your Workers’ Compensation claim has been accepted, denied, or delayed, include the status letter from the insurance carrier.

Note: Do not complete this application if you’re:

•Insured by a Voluntary Plan. Ask your employer for information on how to apply.

•A state government employee in bargaining unit 2, 5, 6, 7, 8, 9, 10, 12, 13, 16, 18, or 19.

Use the Claim for Nonindustrial Disability Insurance (NDI) (DE 8501).

Part B –

Physician/Practitioner’s Certification

Your licensed health professional must complete and sign the “Physician/Practitioner’s Certificate.” They can do this using SDI Online or Part B of this application. If they use Part B, make sure you submit it with Part A.

If you’re under the care of an accredited religious practitioner, they must complete and sign the Claim for Disability Insurance Benefits - Religious Practitioner’s Certificate (DE 2502). To get the DE 2502, call 1-800-480-3287.

We do not accept rubber stamped signatures.

Basic Eligibility

To be eligible for disability benefits, you must:

•Be unable to do your regular work for at least eight consecutive days.

•Be employed or actively looking for work when your disability began.

•Have lost wages because of your disability. If unemployed, you must have been actively looking for work.

•Have earned at least $300 from which State Disability Insurance (SDI) deductions were withheld during the past 5 to 18 months. See “Your Benefit Amounts” in the next column.

•Be under the care and treatment of a licensed health professional during the first eight days of your disability. The start date of your claim can be adjusted to meet this requirement. You must remain under care and treatment to continue receiving benefits.

•Submit your application within 49 days of the date your disability began or you may lose benefits.

Your Rights

Information about your claim is confidential, except for the purposes allowed by law. You have the right to inspect any personal records we have about you and ask that we correct our records if you believe they are not accurate, relevant, timely, or complete (Civil Code, section 1798.34, and 1798.35).

Certain types of information are exempt from disclosure to you:

•Medical or psychological records where knowledge of the contents might be harmful to the subject.

•Records of active criminal, civil, or administrative investigations.

If you’re denied access to records that you believe you have a right to inspect, or if your request to amend your records is refused, you may file an appeal with an SDI office. You may request a copy of your file by calling us at 1-800-480-3287 (Civil Code, section 1798.40).

Your licensed health professional must complete the medical certification of your disability. A licensed midwife or nurse-midwife can complete the medical certification for disabilities related to normal pregnancy or childbirth.

If you’re under the care of a religious practitioner, they must complete and sign the Claim for Disability Insurance Benefits – Religious Practitioner’s Certificate (DE 2502). To get the DE 2502, call 1-800-480-3287. Certification by a religious practitioner is acceptable only if the practitioner has been accredited by the EDD.

We may need an independent medical examination to determine your eligibility.

Ineligibility

Apply for benefits even if you’re not sure you’re eligible. If we find you ineligible for all or part of your claim, we will let you know. You may not be eligible if:

You also have the right to appeal any disqualification, overpayment, or penalty. Instructions on how to appeal are provided on documents that can be appealed. If you file an appeal and your disability continues, you must complete and return continued claim certifications.

Your Benefit Amounts — Generally, your claim begins on the date your disability begins. The first day you cannot do your regular work is the date your disability begins.

We calculate your weekly benefit amount using your base period. The date your disability begins determines your base period unless we adjust the claim effective date. If you want your claim to begin later so that you will have a different base period, call 1-800-480-3287 before you submit your application.

Your base period covers 12 months and is divided into four consecutive quarters. It includes wages subject to SDI tax that you were paid about 5 to 18 months before your disability claim began. Your base period does not include wages being paid at the time the disability began.

•You’re claiming or receiving unemployment or Paid Family Leave benefits.

•Your disability began while committing a crime resulting in a felony conviction.

•You’re receiving Workers’ Compensation benefits at a weekly rate equal to or greater than the disability rate.

•You’re in jail or prison because you were convicted of a crime.

•You’re a resident in an alcoholic recovery home or drug-free residential facility that is not licensed and certified by the state.

•You do not submit to an independent medical examination, if requested.

Fraud

Making false statements or withholding information to receive benefit payments is a felony. Penalties may include fines, a loss of benefits, and criminal prosecution. To detect and discourage fraud, we monitor claims, investigate suspicious activity, and seek restitution and conviction through prosecution (CUIC, sections 2101, 2116, and 2122).

Your Responsibilities

•Submit your application within 49 days of the date your disability began. If your application is late, include a written explanation of why it’s late.

•Read the instructions on all forms you receive from us. If you’re not sure about what you need to do, contact a disability office (edd.ca.gov/Office_Locator).

•You must let us know in writing, through SDI Online, or by phone if you:

-Change your address or phone number.

-Return to part-time or full-time work.

-Recover from your disability.

-Receive any type of income.

Keep an appointment for an independent medical examination, if requested.

•Include your name and Social Security number used to obtain benefits or Claim ID number on all correspondence.

Use the following information to determine your base period.

•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.

Your highest-earning quarter determines your weekly benefit amount. You may not change the start 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:

•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 that are being medically treated do not have this limitation.

Contact a disability office (edd.ca.gov/Office_Locator) for more information if:

•You do not have sufficient base period wages and your disability continues. You may be able to use a later start date on your claim.

•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.

•During your base period you were in the US military service, received Workers’ Compensation benefits, or did not work because of a labor dispute. You may be entitled to substitute wages paid in prior quarters either to make your claim valid or to increase your benefit amount.

How Benefits Are Paid

When we receive your completed application, we will mail you a Notice of Computation (DE 429D), which lets you know what your weekly payments could be. We may ask for more information to determine your eligibility.

If you’re eligible to receive benefits, you have the option to receive payments by direct deposit, debit card, or by check. Direct deposit is the fastest and most secure way to receive your payments.

To receive your payments by direct deposit, you must apply using SDI Online (edd.ca.gov/sdi_online).

You do not have to accept payments by direct deposit or debit card. To receive your payments by check, allow 7 to 10 days for delivery by US mail. Select your preferred payment method in question A39.

Most claims are processed and payments issued within 14 days of receiving both Part A and Part B of the application. The first seven days of your claim is a non-payable waiting period.

If you’re eligible for further benefits, we will send payments automatically or enclose a continued claim certification form for the next period. 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’re eligible unless benefits are reduced. See “Benefit Reductions” below. If you receive disability benefits in place of unemployment or Paid Family Leave benefits, the amounts paid will be reported to the IRS. Contact the IRS (irs.gov) for specific tax information.

Benefit Reductions

Under certain circumstances, you may not be eligible for benefits for a period of your claim or you may be entitled only to partial benefits. We will determine if benefits must be reduced. The following types of income should be reported to us even though they may not always affect your benefits:

•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

Failure to report your income could result in an overpayment, penalties, and a false statement disqualification. In addition, your benefits may be reduced because of a prior unemployment, Paid Family Leave, or disability overpayment, or for delinquent court- ordered support payments.

Benefit Interruption and Termination

We will send a Notice of Final Payment when records show you have:

•Been paid up to the date your licensed health professional estimated as your date of recovery. If your disability continues, ask your licensed health professional to complete and return the Physician/Practitioner’s Supplementary Certificate (DE 2525XX) enclosed with the Notice of Final Payment.

•Recovered or returned to work. If you return to work but are again unable to do your regular work because of a disability, immediately submit an application and report the dates you worked.

Overpayment

An overpayment results when you receive disability benefit payments you were not eligible to receive. Once we determine that you were overpaid, we will contact you to explain the reason. It’s important that you complete and return all information requests, as there are instances when an overpayment can be waived.

If we determine that you were overpaid and the overpayment cannot be waived, you must repay the money. Payments issued after an overpayment is established may be reduced by 25 to 100 percent to collect your overpayment. We will send you a Notice of Overpayment Offset (DE 826) if your weekly benefit amount is reduced due to a disability, Paid Family Leave, or unemployment overpayment.

Disqualification

We will consider all available information before paying or disqualifying your claim. Benefits will be paid only for the days you’re eligible. If payment is denied or reduced, we will send you a Notice of Determination (DE 2517) explaining the reason and the time period.

If you knowingly report incorrect information or willfully withhold information, we may issue false statement disqualifications of up to 92 days. This can apply if you accept

disability benefit payments you know include days you should not be paid, such as days after you returned to work. In addition, any overpayment will be increased by a 30 percent penalty.

Special Circumstances

•When you suffer a work-related injury or illness, report it to your employer and have your licensed health professional send a report to your employer’s Workers’ Compensation insurance carrier. If the Workers’ Compensation insurance carrier delays or refuses payments, we may pay you benefits while your case is pending. However, we will pay benefits only for the period of your disability 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 disability rate, we can pay you the difference.

For information about Workers’ Compensation, contact your local Workers’ Compensation Appeals Board office (dir.ca.gov).

•For pregnancy, your disability begins the first day you’re not able to do your regular work. Disability benefits will be paid for the period of time reported on your “Physician/Practitioner’s Certificate.” Pregnancy disability claims should not be submitted until after the eighth day following the date your licensed health professional certifies your disability. We will send an Application for Paid Family Leave Benefits – Bonding for New Mother (DE 2501FP) with your final disability payment to transition to a bonding claim.

•For child support questions, contact the Department of Child Support Services at 1-866-249-0773.

•For spousal or parental support questions, contact the District Attorney’s office administering the court order.

•If a family member must stop work to care for you, or if you stop work to care for a seriously ill family member, visit edd.ca.gov/PaidFamilyLeave or contact the program at 1-877-238-4373 for more information.

•If you expect your disability to be long-term or permanent, contact the Social Security Administration before you finish collecting your disability benefits. For information, call the Social Security Administration toll-free at 1-800-772-1213.

•If you have a disability that prevents you from getting or keeping a job, the Department of Rehabilitation may be

•able to help you with vocational training, education, career opportunities, independent living, and use of assistive technology.

•If a person receiving disability benefits dies, an heir or legal representative should report the death to us. Benefits are payable through date of death.

SAMPLE, this page for reference only

Application for Disability

Insurance Benefits

Health Insurance Portability and Accountability Act (HIPAA) Authorization

S a m p l e

C l a i m a n t

I authorize

G e o f f B o o k e r

(Person or 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 or managers and any other EDD employee who may need to access this information in order to process my claim or determine eligibility for State Disability Insurance benefits.

I understand that the EDD is not a health plan or health care provider, so the information released to the EDD may no longer be protected by federal privacy regulations

(45 CFR Section 164.508(c)(2)(iii)). The 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 15 years from the date received by the 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 the 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.

SAMPLE, this page for reference only

Your disability application can also be filed online at edd.ca.gov

Print with black ink.

Part A - Claimant’s Statement

A1. Your Social Security Number

0 0 00 0 0 0 0 0

A2. If you have previously been assigned an EDD customer account number, enter that number here

N o

S a m p l e

C l a i m a n t

A9. If you have worked under any other names, enter them here (for example, a maiden name or chosen name)

A10. Your home phone number and area code

9 9 9 0 2 3 6 7 8 9

A11. Your cell phone number and area code

1 1 1 0 0 20 0 4 7

A12. Language you prefer to use

A13. Your mailing address. Enter a PO Box or the Number, Street, Apartment, Suite, Space#, or PMB# (Private Mail Box)

1 2 3 A n y S t r e e t

A n y t o w n

C A 1 2 3 4 5

A14. Address where you live. Required if different from your mailing address.

Number, Street, Apartment or Space#

A15. Your last or current employer - if your last or current employment was self-employment, enter “self” and fill-in this option. Name of your employer [State Government Employees: provide the agency name (for example: CalTrans)]

Self

R o a d r u n n e r P a s t r i e s

Number, Street, Suite# (State Government Employees: please provide the address of your personnel office)

A16. At any time during your disability, were you in the custody of law enforcement authorities because you were convicted of violating a law or ordinance?

Yes X No

A17. Before your disability began, what was the last day you worked?

0M 1M 2D 5D 2Y 0Y 2Y 5Y

A18. When did your disability begin?

0M 1M 2D 5D 2Y 0Y 2Y 5Y

A20. Since your disability began, have you worked or are you working any full or partial days?

A19. Date you want your claim to begin if different than the date entered in A18

M M D D Y Y Y Y