Structure
Misconceptions
The EDD DE 2501 form, used in California for disability insurance claims, often leads to confusion. Here are ten common misconceptions surrounding this important document.
- The DE 2501 form is only for employees. Many believe that only traditional employees can file this form. In reality, self-employed individuals and independent contractors can also apply for disability benefits using this form.
- You must be unable to work to file the DE 2501. Some think that they need to be completely unable to work. However, the form allows for partial disabilities as well, where individuals can still work in a limited capacity.
- The DE 2501 form is only for physical disabilities. There’s a misconception that this form is strictly for physical ailments. It also covers mental health issues, as long as they impair one’s ability to work.
- You can submit the DE 2501 form at any time. Many assume there are no deadlines. In fact, the form must be submitted within a specific timeframe after the disability begins, typically within 49 days.
- Your employer handles the DE 2501 for you. Some individuals think their employer will take care of this process. It’s the responsibility of the employee to complete and submit the form.
- Filing the DE 2501 guarantees approval. There is a belief that submitting the form automatically means benefits will be granted. Approval depends on meeting eligibility criteria and providing adequate documentation.
- You can only file once for a disability. Many believe that they can only file a claim once. In reality, individuals can file multiple claims for different disabilities over time.
- The DE 2501 form is the same as other EDD forms. Some think all EDD forms are interchangeable. Each form serves a distinct purpose, and the DE 2501 is specifically for disability insurance claims.
- All medical providers can certify your disability. There’s a misconception that any healthcare provider can fill out the medical certification section. Only licensed professionals in specific fields can certify disabilities for this form.
- Submitting the DE 2501 is the end of the process. Many assume that once the form is submitted, no further action is needed. In fact, claimants may need to respond to additional requests for information or documentation from EDD.
Understanding these misconceptions can help individuals navigate the process more effectively and ensure they receive the benefits they deserve.
Detailed Steps for Filling Out EDD DE 2501
Filling out the EDD DE 2501 form is an important step for individuals seeking disability benefits. Once you have completed the form, it is essential to submit it promptly to ensure that your application is processed without unnecessary delays.
- Begin by gathering your personal information, including your name, address, and Social Security number.
- Provide details about your employment, such as your employer's name, address, and your job title.
- Indicate the date your disability began. Be as precise as possible.
- Complete the section regarding your medical condition. Describe your injury or illness clearly.
- Have your healthcare provider fill out the certification section. This part confirms your disability and the expected duration.
- Review the entire form for accuracy. Ensure all sections are filled out completely.
- Sign and date the form at the designated area. Your signature is necessary for processing.
- Make a copy of the completed form for your records.
- Submit the form to the appropriate EDD office. Check for the correct mailing address or submission method.
Document Preview
Claim for Disability Insurance (DI) Benefits
The State Disability Insurance (SDI) program provides worker-funded benefits to eligible workers who have a
full or partial loss of wages due to disabilities that are not work related. 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.
Please read instruction and information pages (A through D) before completing the enclosed forms.
For faster processing, file your claim using SDI Online at edd.ca.gov. If you file online, do NOT mail this form to
the Employment Development Department (EDD).
DO NOT COMPLETE THIS FORM IF YOU ARE:
• Insured by a Voluntary Plan. Ask your employer for the proper forms.
• Filing for Non-Industrial Disability Insurance benefits. State government employees refer to your
personnel office.
If you cannot complete this form due to your disability, or if you are an authorized representative filing for benefits
on behalf of an incapacitated or deceased claimant, call 1-800-480-3287 or visit the EDD website to send an
online message using Ask EDD at askedd.edd.ca.gov.
HOW TO COMPLETE THIS FORM
• Use black ink only.
• Type or write clearly within the boxes provided.
• Enter your Social Security number on all pages of the claim form including attachments.
• Do not fax the form.
• Mail the completed form to the EDD in the envelope provided. 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. You
may lose benefits if your claim is late.
1. Complete ALL items in “PART A – CLAIMANT’S STATEMENT” and sign box A40. Errors or missing
information may cause your claim to be returned and delay payment. For box A13, the United States
Postal Service will not deliver mail to a private mail box unless it is preceded by the initials “PMB.”
2. Have your physician/practitioner complete and sign “Part B – PHYSICIAN/PRACTITIONER’S
CERTIFICATE.” Certification may be made by a licensed physician or practitioner authorized to certify
to a patient’s disability or serious health condition pursuant to CUIC, section 2708. If you are under the
care of an accredited religious practitioner, obtain a Claim for Disability Insurance Benefits - Religious
Practitioner’s Certificate (DE 2502) by calling 1-800-480-3287 and ask your religious practitioner to
complete and sign it. Rubber stamp signatures are not accepted.
3. You should carefully decide the date you want your claim to begin because it may affect your benefit
amount. See “YOUR BENEFIT AMOUNTS” on page B for information.
4. If you have a work-related disability, complete questions A31 to A38. If your workers’ compensation
claim has been accepted, denied, or delayed, please include the status letter from the carrier.
5. Place the completed, signed form(s) in the envelope provided. A claim is complete when “PART A –
CLAIMANT’S STATEMENT” and “PART B – PHYSICIAN/PRACTITIONER’S CERTIFICATE” are received.
Claims are generally processed within 14 days.
6. Keep these instructions and information pages (A through D) for future reference.
The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to
individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling
1-866-490-8879 (voice). TTY users, please call the California Relay Service at 711.
DE 2501 Rev. 81 (3-20) (INTERNET) Page 1 of 13 Instruction & Information A
BASIC ELIGIBILITY. DI benefits can be paid only after you meet all of
the following requirements:
• You must be unable to do your regular or customary work for at
least eight consecutive days.
• You must be employed or actively looking for work at the time
you become disabled.
• You must have lost wages because of your disability or, if
unemployed, have been actively looking for work.
• You must have earned at least $300 in wages from which SDI
deductions were withheld during your established base period
(see “YOUR BENEFIT AMOUNTS” in the next column).
• You must be under the care and treatment of a licensed physician/
practitioner or accredited religious practitioner during the first
eight days of your disability. (The beginning date of a claim can be
adjusted to meet this requirement.) You must remain under care
and treatment to continue receiving benefits.
• You must complete and submit a claim form within 49 days of
the date you became disabled or you may lose benefits.
• Your physician/practitioner must complete the medical
certification of your disability. A licensed midwife or nurse-
midwife may complete the medical certification for disabilities
related to normal pregnancy or childbirth. If you are under the
care of a religious practitioner, request a DE 2502 from the SDI
office. Certification by a religious practitioner is acceptable only if
the practitioner has been accredited by the EDD.
We may require an independent medical examination to determine
your initial or continuing eligibility.
INELIGIBILITY. You may apply for benefits even if you are not sure you
are eligible. If you are found to be ineligible for all or part of a period
claimed, you will be notified of the ineligible period and the reason.
You may not be eligible for DI benefits if you:
• are claiming or receiving Unemployment Insurance or Paid Family
Leave benefits.
• became disabled while committing a crime resulting in a felony
conviction.
• are receiving Workers’ Compensation benefits at a weekly rate
equal to or greater than the SDI rate.
• are in jail or prison because you were convicted of a crime.
• are a resident in an alcoholic recovery home or drug-free
residential facility that is not both licensed and certified by the
state in which the facility is located.
• fail to submit to an independent medical examination when
requested to do so.
FRAUD. Under sections 2101, 2116, and 2122 of the California
Unemployment Insurance Code, it is a violation to willfully make
a false statement or knowingly conceal a material fact in order to
obtain the payment of any benefits, such violation being punishable
by imprisonment and/or by a fine not exceeding $20,000 or both. To
detect and discourage fraud, SDI continually monitors claim payments,
vigorously investigates suspicious activity, and will seek restitution
and conviction through prosecution.
YOUR RESPONSIBILITIES.
• File your claim and other forms completely, accurately, and in a
timely manner. If a form is late, attach a written explanation of
the reason(s) to the form.
• Thoroughly read the instructions on this and all other forms your
receive from SDI. If you are not sure what is required, contact the
SDI office.
• Report to SDI in writing, electronically, or by telephone any:
- change of address or telephone number.
- return to part-time or full-time work.
- recovery from your disability.
- income you receive.
Keep an appointment for an independent medical examination, if
requested.
• Include your name and Social Security number or Claim ID
number on all correspondence.
YOUR RIGHTS. Information about your claim will be kept
confidential, except for the purposes allowed by law. California
Civil Code, section 1798.34, gives you the right to inspect any
personal records maintained about you by the EDD. Section 1798.35
permits you to request that the record be corrected if you believe
it is not accurate, relevant, timely, or complete. Certain types of
information that would generally be considered personal are exempt
from disclosure to you: medical or psychological records where
knowledge of the contents might be harmful to the subject (Civil Code,
section 1798.40); records of active criminal, civil, or administrative
investigations (Civil Code, section 1798.40). If you are denied access
to records which you believe you have a right to inspect or if your
request to amend your records is refused, you may file an appeal with
the SDI office. You may request a copy of your file by calling SDI at
1-800-480-3287.
You also have the right to appeal any disqualification, overpayment, or
penalty. Specific instructions on how to appeal will be provided on any
appealable document you receive. If you file an appeal and you remain
disabled, you must continue to complete and return continued claim
certifications.
YOUR BENEFIT AMOUNTS. Your claim begins on the date your
disability began. SDI calculates your weekly benefit amount using
your base period. The date your disability began determines your base
period, unless the claim effective date is adjusted by SDI. If you want
your claim to begin later so that you will have a different base period,
please call SDI at 1-800-480-3287 before you file your claim.
This base period covers 12 months and is divided into four consecutive
quarters. Your base period includes wages subject to SDI tax which you
were paid approximately 5 to 17 months before your disability claim
begins. Your base period does not include wages being paid at the time
the disability begins. For a disability claim to be valid, you must have
at least $300 in wages in the base period. Using the following, you
may determine the base period for your claim.
• 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.
The quarter of your base period in which you were paid the highest
wages determines your weekly benefit amount. You may not change
the beginning 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 as follows:
• 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 which are being
medically treated do not have this limitation.)
Contact the SDI office to inquire and provide additional information
if your situation fits any of these circumstances: If you do not have
sufficient base period wages and you remain disabled, you may be able
to establish a valid claim by using a later beginning date. If 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. Additionally, you may
be entitled to substitute wages paid in prior quarters either to make
your claim valid or to increase your benefit amount if during your
base period you were in the U.S. military service, received Workers’
Compensation benefits, or did not work because of a labor dispute.
DE 2501 Rev. 81 (3-20) (INTERNET)
Page 2 of 13 Instruction & Information
B
HOW BENEFITS ARE PAID. When your completed “PART
A – CLAIMANT’S STATEMENT” and “PART B – PHYSICIAN/
PRACTIONER’S CERTIFICATE” are received, the SDI office will
notify you by mail of your weekly and maximum benefit amounts
and may request additional information if needed to determine
your eligibility. If you are eligible to receive benefits, you have
an option in how you receive your benefit payments. The EDD
issues benefit payments by the EDD Debit Card
SM
or by check.
The EDD Debit Card is the fastest and most secure way to receive
your benefits. You do not have to accept the EDD Debit Card, to
receive your benefits by check mailed from the EDD allow 7-10
days for delivery by US mail. The majority of claims are processed
and payments are issued within 14 days of receipt of both the
claimant’s and the physician/practitioner’s portions of the claim.
The first seven days of your claim is a non-payable waiting period.
If you are eligible for further benefits, additional payments will be
sent automatically or a continued claim certification form for the
next period will be enclosed. 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 are eligible unless benefits are reduced
for some reason. (See “BENEFIT REDUCTIONS” below.) If you
receive DI benefits in place of Unemployment Insurance or Paid
Family Leave benefits, the amounts paid will be reported to the
Internal Revenue Service. Contact the Internal Revenue Service for
more specific tax information.
BENEFIT REDUCTIONS. Under certain circumstances, you may
not be eligible for a period of your claim or you may be entitled
only to partial benefits. SDI will determine whether or not benefits
must be reduced. The types of income shown in the following list
should be reported to SDI even though they may not always affect
your benefits. Failure to report your income could result in an
overpayment, penalties, and a false statement disqualification.
• 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
In addition, your benefits may be reduced because of a prior
Unemployment Insurance, Paid Family Leave, or DI overpayment
or for delinquent court-ordered support payments.
BENEFIT INTERRUPTION and TERMINATION. A Notice of Final
Payment will be issued when records show you have:
• been paid to your physician/practitioner’s estimated date
of recovery. If you are still disabled, ask your physician/
practitioner to complete and return the Physician/Practitioner’s
Supplementary Certificate (DE 2525XX) (enclosed with the
Notice of Final Payment).
• recovered or returned to your work. If you return to work and
become disabled again, immediately submit a new claim form
and report the date(s) you worked.
OVERPAYMENT. An overpayment results when you receive DI
benefits you were not entitled to receive. Once SDI determines
that you were overpaid, the SDI office will contact you to explain
the reason for your overpayment. It is important that you complete
and return all information requests, as there are some instances
when an overpayment can be waived. If it is determined that
you were overpaid and the overpayment cannot be waived, you
must repay this money. Benefits issued after an overpayment is
established may be reduced by 25 to 100 percent to collect your
overpayment. You will receive a Notice of Overpayment Offset
(DE 826) if a reduction is taken for either a DI, Paid Family Leave,
or Unemployment Insurance overpayment.
DISQUALIFICATION. All available information will be considered
before paying or disqualifying your claim. Benefits will be paid
only for the days to which you are entitled. If payment of benefits
is denied or reduced, you will be issued a Notice of Determination
(DE 2517) stating the reason for the disqualification and the time
period.
If you deliberately report incorrect information or if you willfully
omit or withhold information, false statement disqualifications of
up to 92 days are assessed. This may apply if you accept disability
benefit payments you know include days for which you should not
be paid, such as days after you returned to work. In addition, any
resulting overpayment will be increased by a 30 percent penalty
assessment.
SPECIAL CIRCUMSTANCES.
Work-related Disability. If you have suffered a work-related injury
or illness, report it to your employer and have your physician/
practitioner submit a report to your employer’s Workers’
Compensation insurance carrier. If the Workers’ Compensation
insurance carrier delays or refuses payments, SDI may pay you
benefits while your case is pending. However, SDI will pay benefits
only for the period you are disabled 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 SDI rate, SDI may
pay you the difference between the two rates. For Workers’
Compensation information and assistance, call your local Workers’
Compensation Appeals Board office. You will find their listing
in the State government pages of your telephone book under
California, State of; Industrial Relations Department; Workers’
Compensation Appeals Board.
Pregnancy. As with any medical condition, the disability period
begins with the first day you are unable to do your regular
or customary work. DI benefits will be paid for the period of
time supported by your physician/practitioner’s certification.
Pregnancy-related disability claims should NOT be submitted until
after the eighth day following the date your physician/practitioner
certifies you are disabled.
Bonding with a New Child. Contact the EDD’s Paid Family Leave
program at 1-877-238-4373. With the final DI benefit payment
issued to a new mother, a transition bonding claim form, Claim for
Paid Family Leave (PFL) Benefits –
New Mother (DE 2501FP) will
be sent automatically by mail or electronically to
your online State
Disability Insurance Online Service account if established.
Child Support Questions. Contact the Department of Child Support
Services at 1-866-249-0773.
Spousal or Parental Support Questions. Contact the District
Attorney’s office administering the court order.
Family Care. If a family member must stop work to care for you, or
if you stop work to care for a seriously ill family member, please
visit edd.ca.gov or contact the EDD’s Paid Family Leave program at
1-877-238-4373 for more information.
Long-term or Permanent Disability. If you expect your disability
to be long-term or permanent, contact the Social Security
Administration well before you exhaust your DI benefits. For
information, call the Social Security Administration toll-free at
1-800-772-1213.
Rehabilitation. If you have a disability which prevents you from
getting or keeping a job, the Department of Rehabilitation may
be able to assist you with vocational training, education, career
opportunities, independent living, and use of assistive technology.
Job Training. Contact a One-Stop Career Center (1-877-872-5627
or servicelocator.org) for services available in your area.
Seeking Work. Contact the EDD for information and assistance
concerning employment opportunities and Unemployment
Insurance benefits.
Death of Claimant. If a person receiving DI benefits dies, an heir
or legal representative should report the death to SDI. Benefits are
payable through date of death.
DE 2501 Rev. 81 (3-20) (INTERNET)
Page 3 of 13 Instruction & Information
C
DE 2501 Rev. 81 (3-20) (INTERNET) Page 4 of 13 Instruction & Information D
EDD Debit Card Fee Disclosures
Monthly Fee
$0
Per purchase
$0
ATM withdrawal
$0 in-network
$1.00** out-of-network
Cash reload
N/A
ATM balance inquiry $0
Customer service $0 per call
Inactivity $0
We charge 5 other types of fees. Here are some of them:
Replacement card, express delivery $10.00
Each international transaction 2%
*This document entitled ‘Fee Disclosure and Other Important Disclosures’ is included with, and incorporated
in, the California Employment Development Department Debit Card Account Agreement.
**Fees can be lower depending on how and where this card is used.
See the materials you received with your card for free ways to access your funds and balance information.
No overdraft/credit features.
Your funds are eligible for FDIC insurance.
For more information about prepaid cards, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services in the cardholder agreement.
DE 2501 Rev. 81 (3-20) (INTERNET) Page 5 of 13 Instruction & Information E
All Fees Amount Details
Spend Money
Per purchase with PIN $0
Per purchase with signature $0
Get Cash in the U.S.
ATM withdrawal, in-network $0 “In Network” refers to Bank of America ATMs. Locations can
be found at www.bankofamerica.com/eddcard. You will not be
charged a fee by Bank of America.
ATM withdrawal,
out-of-network
$1.00 You will be charged this fee after 2 free for each deposit. “Out of
Network” refers to all the ATMs outside of Bank of America ATMs.
You may also be charged a fee by the ATM operator even if you do
not complete a transaction.*
Bank teller cash withdrawal $0 Available at financial institutions that accept Visa cards. Limited to
available balance only.
Emergency cash transfer,
domestic
$15.00 All emergency cash transfers must be initiated through the Prepaid
Debit Card Customer Service Center.
Information
Customer service $0
Online account information $0
Account alert service $0
ATM balance inquiry $0
Using your card outside the U.S.
Each international
transaction
2% Of total U.S. Dollar amount of transaction
International ATM
withdrawal
$1.00 This is the Bank of America fee. You may also be charged a fee by
the ATM operator, even if you do not complete a transaction.
Other
Online funds transfer $0
Replacement card, domestic $0
Replacement card, express
delivery
$10.00 Additional charge
Replacement card,
international
$10.00 Additional charge
Inactive account $0
*ATM owners may impose an additional “convenience fee” or “surcharge fee” for certain ATM transactions (a sign should be posted at the
ATM to indicate additional fees); however you will not be charged any additional convenience fee or surcharge fee at a Bank of America
ATM. A Bank of America ATM means an ATM that prominently displays the Bank of America name and logo.
Your funds are eligible for FDIC insurance. Your funds are insured up to $250,000 by the FDIC in the event Bank of America, N.A. fails, if
specific deposit insurance requirements are met. See fdic.gov/deposit/deposits/prepaid.html for details.
No overdraft/credit feature.
Contact Bank of America by calling 1.866.692.9374, 1.866.656.5913 (TTY), or 1.423.262.1650 (Collect, when calling outside the U.S.), by
mail at Bank of America, PO Box 8488, Gray, TN 37615-8488, or visit www.bankofamerica.com/eddcard.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
If you have a complaint about a prepaid account, call the Consumer Financial Protection Bureau at 1-855-411-2372 or visit
cfpb.gov/complaint.
DE 2501 Rev. 81 (3-20) (INTERNET) Page 6 of 13 Instruction & Information F
FEDERAL PRIVACY ACT. The EDD requires disclosure of Social Security numbers to comply with California Unemployment Insurance
Code, sections 1253 and 2627; with California Code of Regulations, Title 22, sections 1085, 1088, and 1326; with Code of Federal
Regulations, Title 20, Part 604; and with U.S. Code, Title 8, sections 1621, 1641, and 1642.
INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information
from individuals:
Agency Name:
Employment Development Department (EDD)
Title of Official Responsible for Information Maintenance:
Manager, EDD State Disability Insurance Office
Local Contact Person:
Manager, EDD State Disability Insurance Office
Contact Information:
You may contact State Disability Insurance by calling 1-800-480-3287. A list of
State Disability Insurance local office locations can be found on the Internet at
edd.ca.gov/disability/Contact_DI.htm. The address and phone number of State
Disability Insurance will also appear on the “Notice of Computation,” DE 429D,
issued at the time your benefit determination is made.
Maintenance of the information is authorized by:
California Unemployment Insurance Code, sections 2601 through 3272.
California Code of Regulations, Title 22, sections 2706-1, 2706-3, 2708-1, and 2710-1.
Consequences of not providing all or any part of the requested information:
• Failure to supply any or all information may cause delay in issuing benefit payments or may cause you to be denied benefits to
which you are entitled.
• If you willfully make a false statement or representation or knowingly withhold a material fact to obtain or increase any benefit or
payment, the EDD will disqualify you from receiving benefits and/or services and may initiate criminal prosecution against you.
Principal purpose(s) for which the information is to be used:
• To determine eligibility for Disability Insurance benefits.
• To be summarized and published in statistical form for the use and information of government agencies and the public (your
name and identification will not appear in publications).
• To be used to locate persons who are being sought for failure to provide child, spousal, or other court-ordered support.
• To be used by other governmental agencies to determine eligibility for public social services under the provisions of California
Welfare and Institutions Code, Division 9.
• To be used by the EDD to carry out its responsibilities under the California Unemployment Insurance Code.
• To be exchanged pursuant to California Unemployment Insurance Code, section 322, and California Civil Code, section 1798.24,
with other governmental departments and agencies, both federal and state, which are concerned with any of the following:
(1) Administration of an Unemployment Insurance program.
(2) Collection of taxes which may be used to finance Unemployment Insurance or State Disability Insurance.
(3) Relief of unemployed or destitute individuals.
(4) Investigation of labor law violations or allegations of unlawful employment discrimination.
(5) The hearing of workers’ compensation appeals.
(6) Whenever necessary to permit a state agency to carry out its mandated responsibilities where the use to which the
information will be put is compatible with the purpose for which it was gathered.
(7) When mandated by state or federal law. Disclosures under California Unemployment Insurance Code, section 322, will be
made only in those instances in which it furthers the administration of the programs mandated by that Code.
• Pursuant to California Unemployment Insurance Code, sections 1095 and 2714: (1) Information may be revealed to the extent
necessary for the administration of public social services, to the Director of Social Services or his/her representatives, or to
the Director of Child Support Services or his/her representatives; (2) Claimant identity may be released to the Department of
Rehabilitation.
• Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code, sections
1095 and 2714.
Claim for Disability Insurance (DI) Benefits
Health Insurance Portability and Accountability Act (HIPAA) Authorization
(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.
I authorize
Claimant Signature (Do Not Print)
Date Signed
Claimant Social Security Number
Claimant Name
(First) (MI) (Last)
M
M D D Y Y Y Y
DE 2501 Rev. 81 (3-20) (INTERNET) Page 7 of 13
SAMPLE, this page for reference only
Sample Claimant
Geoff Booker
12252015
000000000
Sample Claimant
A1. YOUR SOCIAL SECURITY
NUMBER
A5. IF YOU EVER USED OTHER SOCIAL SECURITY NUMBERS,
ENTER THOSE NUMBERS BELOW
A12. LANGUAGE YOU PREFER TO USE
A13. YOUR MAILING ADDRESS, PO BOX OR NUMBER/STREET/APARTMENT, SUITE, SPACE#, OR PMB#
(PRIVATE MAIL BOX)
A15. YOUR LAST OR CURRENT EMPLOYER - IF YOUR LAST OR CURRENT EMPLOYMENT WAS SELF-EMPLOYMENT, ENTER “SELF” AND FILL-IN THIS OPTION.
CITY
CITY
CITY
NUMBER/STREET/SUITE# (STATE GOVERNMENT EMPLOYEES: PLEASE PROVIDE THE ADDRESS OF YOUR PERSONNEL OFFICE)
A8. YOUR LEGAL NAME (FIRST) SUFFIX
SUFFIX
SUFFIX
ENGLISH
A10. YOUR HOME AREA CODE AND TELEPHONE NUMBER
A11. YOUR CELL AREA CODE AND TELEPHONE NUMBER
A2. IF YOU HAVE PREVIOUSLY BEEN ASSIGNED AN EDD
CUSTOMER ACCOUNT NUMBER, ENTER THAT NUMBER HERE
A4. GENDER
MALE
A3. CALIFORNIA DRIVER
LICENSE OR ID NUMBER
A7. YOUR DATE OF BIRTH
A6. STATE GOVERNMENT EMPLOYEE
(IF “YES” INDICATE BARGAINING UNIT#)
YES
M
M D D Y Y Y Y
NO UNIT#
PART A - CLAIMANT’S STATEMENT
Your disability claim can also be filed online at www.edd.ca.gov
PLEASE PRINT WITH BLACK INK.
SELF
A14. YOUR RESIDENCE ADDRESS, REQUIRED IF DIFFERENT FROM YOUR MAILING ADDRESS
NUMBER/STREET/APARTMENT OR SPACE#
A9. OTHER NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED
(FIRST) (MI) (LAST)
(FIRST)
(MI) (LAST)
A17. BEFORE YOUR DISABILITY BEGAN, WHAT
WAS THE LAST DAY YOU WORKED?
M
M D D Y Y Y Y
A18. WHEN DID YOUR DISABILITY BEGIN?
MM
MM DD DD YY YY YY YY
A21 A. IF YOU RECOVERED, ENTER DATE: A21 B. IF YOU RETURNED TO WORK,
ENTER DATE:
M
M
M
M
D
D
D
D
Y
Y
Y
Y
Y
Y
Y
Y
A20. SINCE YOUR DISABILITY BEGAN, HAVE YOU WORKED OR
ARE YOU WORKING ANY FULL OR PARTIAL DAYS?
YES NO
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 NO
EMPLOYER’S TELEPHONE NUMBER
FEMALE
(MI) (LAST)
SPANISH CANTONESE VIETNAMESE ARMENIAN PUNJABI TAGALOG OTHER
STATE
STATE
STATE
ZIP OR POSTAL CODE
ZIP OR POSTAL CODE
ZIP OR POSTAL CODE
COUNTRY
(IF NOT U.S.A.)
COUNTRY (IF NOT U.S.A.)
COUNTRY (IF NOT U.S.A.)
NAME OF YOUR EMPLOYER [STATE GOVERNMENT EMPLOYEES: PROVIDE THE AGENCY NAME (FOR EXAMPLE: CALTRANS)]
A19. DATE YOU WANT YOUR CLAIM TO BEGIN IF DIFFERENT THAN THE DATE ENTERED IN A18
DE 2501 Rev. 81 (3-20) (INTERNET) Page 8 of 13
SAMPLE, this page for reference only
000000000
999 0236789
499 3111111
123 Any Street
Roadrunner Pastries
647 Armistice Way
Anywhere 66222CA
Anytown CA 12345
111 0020047
Z1234567
01011900
No X
X
X
Sample
X
X
12012015
12162015
Claimant
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
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.
A33. DATE(S) OF INJURY SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM
M
M M M
M
M M M
D
D D D
D
D D D
Y
Y Y Y
Y
Y Y Y
Y
Y Y Y
Y
Y Y Y
A26. IF YOUR EMPLOYER(S) CONTINUED OR WILL CONTINUE TO PAY YOU DURING YOUR DISABILITY, INDICATE
TYPE OF PAY:
A27. MAY WE DISCLOSE BENEFIT PAYMENT
INFORMATION TO YOUR EMPLOYER(S)?
YES NO
OTHER (EXPLAIN)
A28. SECOND EMPLOYER NAME (IF YOU HAVE MORE THAN ONE EMPLOYER)
NUMBER/STREET/SUITE#
CITY
BEFORE YOUR DISABILITY BEGAN, WHAT WAS THE LAST DAY YOU WORKED FOR THIS EMPLOYER?
M
M D D Y Y Y Y
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
A24. WHY DID YOU STOP WORKING? (SELECT ONLY ONE BOX)
LAYOFF UNPAID LEAVE OF ABSENCE VOLUNTARILY QUIT OR RETIRED TERMINATED OTHER REASON
ILLNESS, INJURY, OR PREGNANCY
A29. IF YOU HAVE MORE THAN 2 EMPLOYERS CHECK HERE.
PART A - CLAIMANT’S STATEMENT - CONTINUED
A22. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER
A31. HAVE YOU FILED OR DO YOU INTEND TO FILE FOR WORKERS’ COMPENSATION BENEFITS?
YES - COMPLETE ITEMS A32 THROUGH A38 NO - SKIP ITEMS A33 THROUGH A38
A32. WAS THIS DISABILITY CAUSED BY YOUR JOB?
YES NO
A23. WHAT IS YOUR REGULAR OR CUSTOMARY OCCUPATION?
Constantly lift, carry, push, pull, or otherwise move objects that weigh over 20 lbs.; frequently over 50 lbs.; occasionally over 100 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.
ANNUALSICK VACATION
Paid Time Off
(PTO)
STATE
STATE
ZIP OR POSTAL CODE
ZIP OR POSTAL CODE AREA CODE AND TELEPHONE NUMBER
COUNTRY (IF NOT U.S.A.)
EMPLOYER’S TELEPHONE NUMBER
DE 2501 Rev. 81 (3-20) (INTERNET) Page 9 of 13
SAMPLE, this page for reference only
000000000
Pastry Chef
X
X
Cosmic Cookies
469 Thrifty Way
Bluebell 84369
12162015
CA
ATTORNEY’S ADDRESS NUMBER/STREET/SUITE#
CITY STATE ZIP CODE
WORKERS’ COMPENSATION APPEALS
BOARD/ADJ CASE NUMBER
A38. YOUR ATTORNEY’S NAME (IF ANY) FOR YOUR WORKERS’ COMPENSATION CASE AREA CODE AND TELEPHONE NUMBER EXTENSION (IF ANY)
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)
A39. SELECT YOUR PREFERRED PAYMENT METHOD
o
EDD DEBIT CARD
SM
o
CHECK
A41. IF YOUR SIGNATURE IS MADE BY MARK (X), CHECK THE BOX AND IT MUST BE ATTESTED BY TWO WITNESSES WITH THEIR ADDRESSES.
1st WITNESS SIGNATURE (PRINT AND SIGN)
2nd WITNESS SIGNATURE (PRINT AND SIGN)
NUMBER/STREET/APARTMENT OR SPACE#, PO BOX OR PRIVATE MAIL BOX ADDRESSES NOT ACCEPTABLE.
NUMBER/STREET/APARTMENT OR SPACE#, PO BOX OR PRIVATE MAIL BOX ADDRESSES NOT ACCEPTABLE.
(FIRST) (MI) (LAST)
CITY STATE ZIP CODE
CITY STATE ZIP CODE
A40. 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
DATE SIGNED
DATE SIGNED
A42. CHECK THIS BOX IF YOU ARE THE PERSONAL REPRESENTATIVE SIGNING ON BEHALF OF CLAIMANT AND COMPLETE THE FOLLOWING:
THIS MATTER AS AUTHORIZED BY DECLARATION OF INDIVIDUAL CLAIMING DISABILITY INSURANCE BENEFITS DUE AN INCAPACITATED OR DECEASED
CLAIMANT, DE
2522 (SEE INSTRUCTION & INFORMATION A, UNDER HOW TO APPLY #4) POWER OF ATTORNEY (ATTACH COPY)
, REPRESENT THE CLAIMANT IN
M
M
M
M
M
M
D
D
D
D
D
D
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
PERSONAL REPRESENTATIVE’S SIGNATURE (DO NOT PRINT)
DATE SIGNED
M
M D D Y Y Y Y
I,
PART A - CLAIMANT’S STATEMENT - CONTINUED
A35. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER
DE 2501 Rev. 81 (3-20) (INTERNET) Page 10 of 13
SAMPLE, this page for reference only
000000000
12162015
Sample Claimant
Common PDF Templates
How to Write a Payroll Check - An integral part of an organization’s payroll system.
Printable Roofing Certificate of Completion - Be aware that every individual roofing material must be labeled as per guidelines.
Gift Letter Template - Essential for first-time homebuyers receiving financial assistance from family.
Dos and Don'ts
When filling out the EDD DE 2501 form, it's important to follow certain guidelines to ensure accuracy and efficiency. Here’s a list of things to do and avoid:
- Do read the instructions carefully before starting.
- Do use black or blue ink when filling out the form.
- Do provide accurate personal information, including your Social Security number.
- Do double-check all entries for spelling and numerical accuracy.
- Do sign and date the form before submitting it.
- Don't leave any required fields blank.
- Don't use correction fluid or tape on the form.
- Don't submit the form without making a copy for your records.
- Don't forget to check the submission deadline.
- Don't provide false information, as this can lead to penalties.
Key takeaways
Filling out the EDD DE 2501 form is an important step for those seeking disability benefits in California. Here are some key takeaways to keep in mind:
- Accurate Information is Crucial: Ensure that all personal details, including your name, address, and Social Security number, are filled out correctly. Mistakes can delay your application.
- Obtain a Doctor's Certification: A licensed physician must complete the certification section of the form. This verifies your medical condition and supports your claim for benefits.
- Submit Promptly: After completing the form, submit it as soon as possible. There are deadlines for filing that can affect your eligibility for benefits.
- Keep Copies: Always keep a copy of the completed form for your records. This can be helpful if you need to reference your application later.
Similar forms
The EDD DE 2501 form is similar to the Family and Medical Leave Act (FMLA) certification form. Both documents serve to validate a worker's need for time off due to medical reasons. While the DE 2501 focuses specifically on California's disability insurance benefits, the FMLA form is used nationwide to secure job protection for eligible employees who need to take leave for their own serious health condition or to care for a family member. Each form requires detailed medical information, ensuring that the leave taken is justified and necessary.
Another document that resembles the EDD DE 2501 is the Short-Term Disability (STD) claim form. This form is often utilized by employees seeking benefits from their employer’s disability insurance plan. Like the DE 2501, the STD claim form requires medical documentation to support the claim. Both forms aim to provide financial assistance during periods when an individual is unable to work due to health issues, but the STD claim may have different eligibility requirements and benefits depending on the employer's policy.
The Workers' Compensation claim form is also comparable to the EDD DE 2501. This form is used when an employee suffers an injury or illness related to their job. Both documents necessitate a medical evaluation and documentation. While the DE 2501 is focused on non-work-related disabilities, the Workers' Compensation form is specifically tailored for work-related incidents. Understanding the distinctions and similarities between these forms can help individuals navigate their rights and benefits more effectively.
Lastly, the Social Security Disability Insurance (SSDI) application shares similarities with the EDD DE 2501 form. Both forms are designed to assist individuals who are unable to work due to a disability. The SSDI application is a federal program that provides benefits based on an individual’s work history, whereas the DE 2501 is a state-level form that offers temporary disability benefits. Each requires thorough documentation of the disability and may involve a review process to determine eligibility, underscoring the importance of accurate and complete submissions.
Documents used along the form
The EDD DE 2501 form is a critical document for individuals seeking disability benefits in California. It serves as a claim for Disability Insurance (DI) benefits. However, several other forms and documents are often used in conjunction with the DE 2501 to ensure a comprehensive application process. Below is a list of these important documents.
- EDD DE 2501F: This form is specifically for individuals who are applying for Disability Insurance benefits due to a pregnancy-related condition. It includes additional information relevant to the pregnancy.
- EDD DE 2500: The Claim for Disability Insurance Benefits form is often required for those who need to provide additional details about their disability claim.
- EDD DE 2580: This form is used to provide medical information from the healthcare provider. It must be completed by a doctor to verify the medical condition that is causing the disability.
- EDD DE 2501A: This is the Notice of Computation form. It outlines the benefits you may be eligible for based on your earnings and provides details on the benefit amount.
- EDD DE 2501-1: This form is a request for additional information from the claimant. It may be sent if the EDD requires further clarification regarding the disability claim.
- EDD DE 2545: This form is the Physician's Certificate. It is essential for certifying that the claimant is unable to work due to their medical condition.
- EDD DE 2555: This document is used for reporting any changes in the claimant's situation that may affect their eligibility for benefits, such as returning to work or a change in medical condition.
Understanding these forms and documents is crucial for a smooth application process for Disability Insurance benefits. Properly completing and submitting them can help ensure that individuals receive the support they need during their recovery period.