DE 8501 - First Claim for Nonindustrial Disability Insurance (NDI)

What Is a California State Disability Form PDF?

It is a three-page document used to claim benefits when an employee is unable to work due to illness, injury, or other medical conditions unrelated to their work. It is sometimes also called the Non-Industrial Disability Insurance Claim.

What do I need the DE 8501 for?

• This form is used by state government employees unable to work due to illness, injury, or pregnancy to report their conditions and claim benefits.
• It contains information about the worker, the reasons that prevent them from working, treatment details, and so on.
• It is usually used to report non-work-related injuries or illnesses as well as restrictions related to a person’s pregnancy.
• If the nature of the disability is work-related, the worker must complete other forms under the State Disability Insurance program.

How to Fill Out the EDD Disability Form PDF?

1. The payroll officer or attendance clerk must complete the first part of the document. They should enter the personal details of the employer, information about the government unit, address, and so on, and also indicate their own personal information.
2. The employee themselves must complete the second part. They should enter their name, indicate the period of disability, and answer questions about their current condition.
3. The attending physician must complete the third part. They should indicate personal data, certificate number, examination period, and diagnosis and answer questions regarding the patient’s treatment and well-being.
4. All persons involved in filling out the document must date and sign, confirming the correctness of the information entered.

Organizations that work with the EDD disability form

• California Employment Development Department