Disability Insurance - Forms and Publications

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Forms

• Claim for Disability Insurance (DI) Benefits - DE 2501 Rev. 78 (4-12)
  To submit the DE 2501 electronically, complete a one-time registration to establish an online account. To register, go to the SDI Online page and select SDI Online Registration. Once the registration is complete, you may log in and complete your claim by visiting the SDI Online Login page. To order a claim form, use the Online Forms and Publications page or call 1-800-480-3287 or 1-866-658-8846 (en español).

• Claim for Disability Insurance (DI) Benefits - Spanish
• DE 2501/S - Rev. 78 (4-12)
  To submit the DE 2501/S electronically, complete a one-time registration to establish an online account. To register, go to the SDI Online page and select SDI Online Registration. Once the registration is complete, you may log in and complete your claim by visiting the SDI Online Login page. To order a claim form, use the Online Forms and Publications page or call 1-800-480-3287 or 1-866-658-8846 (en español).

• Request for Continued Benefits – Physician’s Supplementary Certificate DE 2525XX Rev. 3 (3-12)
  If you will be disabled beyond the original period established on your claim, have your doctor complete and submit the DE 2525XX online by accessing SDI Online. To order the form, call 1-800-480-3287 or 1-866-658-8846 (en español).
• Use a Computer to Fill In Forms
  • A Nurse Practitioner Certification for Disability Insurance Benefits, DE 2509A must accompany a Claim for Disability Insurance Benefits (DE 2501); if a nurse practitioner is certifying a Claim for Disability Benefits for a disability other than normal pregnancy or childbirth.
• Annual Income Report for Disability Insurance Elective Coverage
  • DE 945 - Rev. 3 (12-05)
• Application for Disability Insurance Elective Coverage
  • DE 1378DI - Rev. 43 (2-12)

Note: If your printer has a problem printing the above form, try the “Shrink to Fit” check box under the Acrobat Reader's print function

Publications

• Notice to Employees
  • DE 1857A - Rev. 41 (12-12) - English
  • DE 1857A/C/ - Rev. 41 (12-12) - Chinese
  • DE 1857A/S/ - Rev. 41 (12-12) - Spanish
  • DE 1857A/V/ - Rev. 41 (12-12) - Vietnamese
• Notice to Employees
  (Employers Note: This poster is required to be posted in the workplace of employees who are covered only by Disability Insurance. If your employees are covered by Unemployment Insurance, please post the DE 1857A.)
  • DE 1858 - Rev. 4 (11-08) - English
  • DE 1858/S - Rev. 4 (11-08) - Spanish
• Claim for Disability Insurance (DI) Benefits - Spanish
  • DE 2501/S - Rev. 78 (4-12)
    The DE 2501/S can be submitted online by accessing SDI Online. To order a claim form, use the Online Forms and Publications page or call 1-800-480-3287 or 1-866-658-8846 (en español).
• Disability Insurance Provisions (For Disabilities Beginning on or After January 1, 2003) - To order forms, please use the Online Forms and Publications page.
  • DE 2515 - Rev. 60 (11-12) - English
  • DE 2515/S - Rev. 60 (11-12) - Spanish
• The Medical Provider’s Guide to DI
  • DE 2548 - Rev. 5 (11-12)
• Disability Insurance Elective Coverage - To order forms, please use the Online Forms and Publications page.
  • DE 2565 - Rev. 14 (1-12) - English
  • DE 2565/S - Rev. 14 (1-12) - Spanish
• Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts
  • DE 2588 - Rev. 8 (1-13)
• Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts in Dollar Increments
  • DE 2589 - Rev. 5 (1-13)
• SDI Online Brochure for Physicians/Practitioners
  • DE 2855 (1-13)
• SDI Online Flyer
  • DE 2910A (3-13) - English
  • DE 2910A/S (3-13) - Spanish
• SDI Online Poster
  • DE 2910 (3-13) - English
  • DE 2910/S (3-13) - Spanish
• SDI Online Bookmark for Claimants
  • DE 8717D (3-13) - English
  • DE 8717D/S (3-13) - Spanish
• Tip Sheets
  • SDI Online Tips for Claimants - DE 8515 - Rev. 1 (2-13) - English
  • SDI Online Tips for Physicians and Practitioners - DE 8516 - Rev. 1 (4-13) - English
  • SDI Online Tips for Employers - DE 8518 (4-13) - English
• Fact Sheets
  • Disability Insurance Program - DE 8714C - Rev. 39 (3-13) - English
  • Disability Insurance Program - DE 8714C/S - Rev. 39 (3-13) - Spanish
  • Disability Insurance Elective Coverage Program - DE 8714CC - Rev. 19 (12-11) - English
  • Disability Insurance Elective Coverage Program - DE 8714CC/S - Rev. 19 (8-12) - Spanish
  • State Disability Insurance (SDI) Online - DE8714DI - Rev. 1 (3-13) - English
  • State Disability Insurance (SDI) Online - DE8714DI/S – Rev. 1 (3-13) - Spanish

Paid Family Leave Insurance Forms and Publications