Form DE 2501 - Claim for Disability Insurance Benefits

What is Claim for Disability Insurance Benefits?

The Claim for Disability Insurance (DI) Benefits is form DE 2501, issued by the California Employment Development Department (EDD). Part A is the Claimant's Statement (called "Claim Statement of Employee" on the older edition shown here), which you complete; Part B is the Physician/Practitioner's Certificate, which your licensed health professional completes. The EDD decides the claim under the California Unemployment Insurance Code.

California Disability Insurance pays part of your lost wages when you cannot do your regular work because of a non-work-related illness, injury, pregnancy or childbirth (DI may also pay while a workers' compensation claim is delayed or denied). To qualify you must be unable to do your regular work for at least eight consecutive days, have SDI-covered wages in your base period and be under the care of a licensed health professional; the first seven days of a claim are a non-payable waiting period. If your employer has a Voluntary Plan instead of state SDI, claim through that plan. The claim goes to the EDD, not to your employer. The EDD then notifies your employer that a claim was filed (Notice DE 2503); your medical information stays confidential, and benefit payment information is shared with the employer only if you allow it.

Disability under the code is an illness or injury, physical or mental, that prevents you from performing your regular or customary work; it includes pregnancy, childbirth and related conditions. Make sure DI is the right program for your situation before you file.

What I need the Claim for Disability Insurance Benefits for?

• Filing the claim does not guarantee benefits. It is the first step; the EDD checks that you meet the eligibility rules and decides.
• The EDD needs a claim from any SDI-covered worker who has lost wages because a non-work-related disability keeps them from their regular work. The loss can be partial (for example reduced hours) or full; with a partial loss you receive the lesser of your weekly benefit amount and the wages you lost.
• Employers do not receive the claim form; the EDD sends them a separate notice (DE 2503) asking them to verify the claim information.

How to Fill Out Claim for Disability Insurance Benefits?

The EDD accepts a paper claim only on an original DE 2501 form, which you order from the EDD or get from your health professional, employer or an SDI office; printed or downloaded copies are not accepted. The fastest way is to file online through SDI Online (myEDD). The four-page blank on this page is the 2005 edition (Rev. 75 (3-05)) and can be used only to prepare your answers.

The EDD recommends filing between 9 and 49 days after your disability begins: you can file from day 1, but filing that early may delay your claim, cause loss of benefits or disqualification, and a claim after day 49 may lose benefits. If you file late, explain the reason for the EDD to review. Your health professional's certification is also due within 49 days.

Here is what Part A asks for:

1. Information about you: Social Security number (if you have no SSN of your own, file on paper, leave the SSN field blank, and follow the EDD's instructions for the accompanying letter and proof of wages), the date your disability began, the last day you worked before your disability began, your name, date of birth, address and phone number, why you stopped working;
2. Your last or current employer: name, phone number and address (enter "SELF" if you were self-employed);
3. Your regular occupation, any sick or vacation pay your employer continues, and whether the EDD may disclose benefit payment information to your employer;
4. Any workers' compensation claim and other benefit details the form asks about;
5. The authorization to release medical information, which you sign;
6. Part B is completed and signed by your licensed health professional, on paper or through SDI Online; you do not enter the diagnosis yourself (an accredited religious practitioner certifies on form DE 2502 instead);
7. Sign and date the declaration in Part A.

Organizations that work with Claim for Disability Insurance Benefits

• Employment Development Department State of California.