Disability Insurance – Elective Coverage Forms and Publications
Find important forms, publications, and the specific application for Disability Insurance Elective Coverage (DIEC) on Online Forms and Publications.
Note: The following documents are PDFs. You may need to download the free Adobe Reader to view and print linked documents. Some forms have been prepared so that you can fill in the blanks using a computer.
Follow These Steps
- Select the form you need.
- Enter your information into the fields as directed on the form.
- Print two copies of the form. Keep one for your records and mail one to us.
- Annual Income Report for Disability Insurance Elective Coverage (DE 945)
- Application for Disability Insurance Elective Coverage (DE 1378DI)
- Application for Unemployment Insurance, Disability Insurance, and Paid Family Leave Elective Coverage Under Section 708(a) of the California Unemployment Insurance Code (DE 1378A)
- Request for Preliminary Worker Classification Assessment or Audit Lead Referral (DE 230)
Note: You are reporting confidential information on these forms. Do not use email or other unsecure methods of communication to send these forms to us.
To order, please use the Online Forms and Publications page.
- Disability Insurance Elective Coverage Pamphlet (Digital Version)
- DE 2565D
- DE 2565D/S - Spanish
- DE 2565D/A - Armenian
- DE 2565D/CC – Chinese-Cantonese
- DE 2565D/CM – Chinese-Mandarin
- DE 2565D/K - Korean
- DE 2565D/P - Punjabi
- DE 2565D/T - Tagalog
- DE 2565D/V – Vietnamese
- Disability Insurance Elective Coverage Rate Notice and Instructions for Computing Annual Premiums
- Disability Insurance and Paid Family Leave Weekly Benefit Amounts
- Disability Insurance and Paid Family Leave Weekly Benefit Amounts in Dollar Increments
- Fact Sheet: California Paid Family Leave
- Fact Sheet: Disability Insurance Elective Coverage Program Fact Sheet
- Information Concerning Elective Coverage for State Disability Insurance and Paid Family Leave
- Information Sheet: Elective Coverage for Employers and Self-Employed Individuals
- Information Sheet: Specialized Coverage (Elective Coverage for Exempt Workers)
- State Disability Insurance Bookmark