Disability Insurance and Paid Family Leave – Forms and Publications
All documents on this page are PDFs. Some are samples only. A few forms let you fill them out on your computer. To do this, download and save the form on your computer. Then open them with the free Adobe Reader to fill them out.
You can file your Disability Insurance (DI) or Paid Family Leave (PFL) claim by:
- Using myEDD to access SDI Online (recommended).
- Mailing us one of these forms:
- Application for Disability Insurance Benefits (DE 2501)
- Application for Paid Family Leave Benefits (DE 2501F)
You must use an original paper application form. You cannot print or download a copy. You can get paper applications by:
- Ordering an application online to have it mailed to you.
- Getting the application from your physician/practitioner or employer.
- Visiting an SDI Office.
- Calling us to request a paper application by mail. When prompted, say “Claim form” and follow the instructions on the recording.
- Disability Insurance 1-800-480-3287.
- Paid Family Leave 1-877-238-4373.
Note: Allow up to ten days to receive this form by mail.
The Online Forms and Publications page has all our documents. Many are available to order at no cost. We send them to you by US mail. The web page also includes other publications for you to view and download.
To find documents:
- Visit Online Forms and Publications.
- Select Keyword(s) or Form Number from the dropdown.
- Select Search.
Important: Some forms cannot be ordered or downloaded because we send them to you when needed for your claim.
Example: Physician/practitioner’s Supplementary Certificate (DE 2525XX) to extend a disability claim. You will receive this form with your final payment. If your disability lasts longer than the original period stated on your claim, have your physician/practitioner complete and submit the DE 2525XX.
Your physician/practitioner can find and file this form online using myEDD to access SDI Online or you can give them your paper form. If you lost or did not receive the DE 2525XX, you can request another form. Use your SDI Online account or call 1-800-480-3287 or 1-866-658-8846 (en español).
- Appeal Fact Sheet
- Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts
- Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts in Dollar Increments
- State Disability Insurance Bookmark
- SDI Online Bookmark for Claimants
- DE 8717D - English
- DE 8717D/S - Spanish
Forms
- Example DI claim form for reference only:
- First Claim for Nonindustrial Disability Insurance (DE 8501): Disability claim form for excluded state employees. You must ask your personnel specialist or payroll officer for this form. They must complete Part A before you complete Part B.
- Claim for Disability Insurance Benefits – Religious Practitioner’s Certificate (DE 2502) If you are under the care of an accredited religious practitioner, you can download and print this form. Have your religious practitioner complete and sign the form before sending it to us. A physician/practitioner cannot use or complete this form.
- Declaration of Individual Claiming Benefits Due an Incapacitated or Deceased Claimant (DE 2522/DE 2522J): Use this form if you are filing a DI claim for a person who:
- Is too sick or injured to complete their part of the PFL care claim application.
- Has died.
You can only use this form if you are the claimant's next of kin or are legally allowed to represent them.
Publications
- Disability Insurance Provisions:
- DE 2515D - English (Digital)
- DE 2515/A - Armenian
- DE 2515/CC – Traditional Chinese
- DE 2515/CM – Simplified Chinese
- DE 2515/P - Punjabi
- DE 2515/S - Spanish
- DE 2515/T - Tagalog
- DE 2515/V - Vietnamese
- Important Information for Disability Insurance (DI) Claimants
- Transitioning from Disability Insurance to Paid Family Leave
- DE 8521 - English
- DE 8521/A - Armenian
- DE 8521/CC - Traditional Chinese
- DE 8521/CM - Simplified Chinese
- DE 8521/K - Korean
- DE 8521/P - Punjabi
- DE 8521/T - Tagalog
- DE 8521/V - Vietnamese
- Fact Sheet: Disability Insurance Program
- DE 8714C - English
- DE 8714C/A - Armenian
- DE 8714C/CC - Traditional Chinese
- DE 8714C/CM - Simplified Chinese
- DE 8714C/P - Punjabi
- DE 8714C/S - Spanish
- DE 8714C/T - Tagalog
- DE 8714C/V - Vietnamese
- Fact Sheet: Disability Insurance Elective Coverage Program
- DE 8714CC- English
- Fact Sheet: State Disability Insurance (SDI) Online
- DE 8714DI - English
- DE 8714DI/S - Spanish
Forms
Example PFL claim forms for reference only:
- DE 2501F – Sample form: Order this form or complete it online.
- Claim for Paid Family Leave (PFL) Benefits New Mother(DE 2501FP): If you are a new mother currently receiving pregnancy-related disability benefits, you do not need to request a claim form for PFL benefits. We will automatically send you a DE 2501FP when your pregnancy-related disability claim ends. Complete the application and send it to us to receive PFL bonding benefits.
- Claim for Nonindustrial Disability Insurance – Family Care Leave (NDI-FCL) (DE 8501F): Claim form for excluded state employees. Your personnel specialist or payroll officer must complete Part A.
- Practitioner’s Certification for Paid Family Leave (PFL) Benefits(DE 2502F): If you are under the care of an accredited religious practitioner, you can download and print this form. Have your religious practitioner complete and sign the form before sending it to us. A physician/practitioner cannot complete this form.
- Request to Re-establish a Bonding Claim for Paid Family Leave (DE 2504RE): To submit the DE 2504RE electronically, go to SDI Online.
- Declaration of Claimant (Care Provider) Acting as Authorized Representative for Incapacitated or Deceased Care Recipient (DE 1850J): Use this form if you are filing for a PFL care claim for a person who:
- Is too sick or injured to complete their part of the PFL care claim application.
- Has died.
- Declaration of Individual Claiming Benefits Due an Incapacitated or Deceased Claimant (DE 2522/DE 2522J): Use this form to claim DI or PFL benefits for a claimant who:
- Is too sick or injured to complete their part of the PFL care claim application.
- Has died.
You can only use DE 1850J and DE 2522/DE 2522J if you are the care recipient’s next of kin or are legally allowed to represent them.
Note: English version claim forms cannot be downloaded or reproduced. Spanish claim forms are provided in a downloadable version and may be filled out and printed.
Publications
- Guide for Completing a Claim Form for Paid Family Leave (PFL) Benefits
- DE 2475 - English
- DE 2475/A - Armenian
- DE 2475/CC - Traditional Chinese
- DE 2475/CM - Simplified Chinese
- DE 2475/P - Punjabi
- DE 2475/S - Spanish
- DE 2475/T - Tagalog
- DE 2475/V - Vietnamese
- Paid Family Leave Bonding Benefits Information Sheet
- DE 2508 - English and Spanish
- Paid Family Leave Brochure
- DE 2511D - English (Digital)
- DE 2511D/A - Armenian (Digital)
- DE 2511D/CC - Traditional Chinese (Digital)
- DE 2511D/CM - Simplified Chinese (Digital)
- DE 2511D/K - Korean (Digital)
- DE 2511D/P - Punjabi (Digital)
- DE 2511D/S - Spanish (Digital)
- DE 2511D/T - Tagalog (Digital)
- DE 2511D/V - Vietnamese (Digital)
- Important Information for Paid Family Leave (PFL) Claimants
- California Paid Family Leave for Military Family Members
- DE 2550 - English
- DE 2550/A – Armenian
- DE 2550/CC – Traditional Chinese
- DE 2550/CM – Simplified Chinese
- DE 2550/K– Korean
- DE 2550/S– Spanish
- DE 2550/P– Punjabi
- DE 2550/T– Tagalog
- DE 2550/V- Vietnamese
- Paid Family Leave Booklet
- DE 8520 - English
- Paid Family Leave Flyer
- DE 8519 - English
- DE 8519/A - Armenian
- DE 8519/CC - Traditional Chinese
- DE 8519/CM - Simplified Chinese
- DE 8519/P - Punjabi
- DE 8519/S - Spanish
- DE 8519/T - Tagalog
- DE 8519/V - Vietnamese
- Transitioning from Disability Insurance to Paid Family Leave
- DE 8521 - English
- DE 8521/A - Armenian
- DE 8521/CC - Traditional Chinese
- DE 8521/CM - Simplified Chinese
- DE 8521/K - Korean
- DE 8521/P - Punjabi
- DE 8521/T - Tagalog
- DE 8521/V - Vietnamese
- Fact Sheet: Paid Family Leave
- DE 8714CF - English
- DE 8714CF/S - Spanish
- Fact Sheet: State Disability Insurance (SDI) Online
- DE 8714DI - English
- DE 8714DI/S - Spanish
- Fact Sheet: California Paid Family Leave for Military Families
- DE 8714MA - English
These notices are required to be posted in the workplace where all employees can see them.
Use this poster when employees are covered by Unemployment Insurance, Disability Insurance, and Paid Family Leave:
- Notice to Employees
- DE 1857A - English
- DE 1857A/A - Armenian
- DE 1857A/CC - Traditional Chinese
- DE 1857A/CM - Simplified Chinese
- DE 1857A/P - Punjabi
- DE 1857A/S - Spanish
- DE 1857A/T - Tagalog
- DE 1857A/V – Vietnamese
Use this poster when employees are covered only by Disability Insurance and Paid Family Leave:
When an employee files a claim, we send you a notification. You cannot order or download these notices. By law, you must respond within two working days:
- Notice to Employer of Disability Insurance Claim Filed (DE 2503) – We send this after the employee files a DI claim. It asks you to verify the information the employee provided on their claim. If you have an SDI Online account, you can find it in your Inbox. You can use SDI Online or the paper form to respond.
- Notice of Paid Family Leave (PFL) Claim Filed (DE 2503F) – We send this after the employee has filed a PFL claim. It asks you to verify the information the employee provided on their claim. Return the completed paper form to us to verify the employees’ claim information. This form is not currently available online.
Important: Employers are required to provide new employees and workers who request leave with Disability Insurance and Paid Family Leave information brochures. The digital brochures may be downloaded and provided as official notices to employees:
- Disability Insurance brochure for their own non-work-related illness or injury.
- Paid Family Leave for leave to care for a seriously ill family member, bond with a new child, or a military assist leave.
- Disability Insurance Provisions
- DE 2515D - English (Digital)
- DE 2515/A - Armenian
- DE 2515/CC - Traditional Chinese
- DE 2515/CM - Simplified Chinese
- DE 2515K - Korean
- DE 2515/P - Punjabi
- DE 2515/S - Spanish
- DE 2515/T - Tagalog
- DE 2515/V - Vietnamese
- Paid Family Leave Brochure
- DE 2511D - English (Digital)
- DE 2511D/A - Armenian (Digital)
- DE 2511D/CC - Traditional Chinese (Digital)
- DE 2511D/CM - Simplified Chinese (Digital)
- DE 2511D/K - Korean (Digital)
- DE 2511D/P - Punjabi (Digital)
- DE 2511D/S - Spanish (Digital)
- DE 2511D/T - Tagalog (Digital)
- DE 2511D/V - Vietnamese (Digital)
- SDI Online Tips for Employers
- DE 8518 - English
Forms
Example forms for reference only:
- Claim for Disability Insurance (DI) Benefits (DE 2501) (sample claim form)
- Fill out and submit Part B – Physician/Practitioner’s Certificate. Access this form by logging in to your myEDD account and selecting SDI Online. You can also complete this certification using the paper form.
- Claim for Paid Family Leave Benefits (PFL) Benefits (DE 2501F) (sample claim form)
- Fill out and submit Part D – Physician/Practitioner’s Certification. Access this form by logging in to your myEDD account and selecting SDI Online. You can also complete this certification using the paper form.
- Request for Continued Benefits – Physician/Practitioner’s Supplementary Certificate (DE 2525XX)
- Access this form by logging in to your myEDD account and selecting SDI Online. Or complete this certification using the paper form that your patient will receive by mail with their final payment. Fill out all P/P certificate questions including descriptions and ICD codes. Make sure to sign, date, provide license number and phone number.
- Paid Family Leave (PFL) Supplemental Claim Certification(DE 2525XFA)
- Access this form by logging in to your myEDD account and selecting SDI Online. You can also complete this certification using the paper form that your patient will receive by mail with their final payment. Fill out Physician/Practitioner certificate questions 1 through 4, sign, date, provide license number and phone number.
- Religious practitioner: If you are an accredited religious practitioner, download and print these forms. Do not complete these forms if you are a physician/practitioner.
- For DI: Claim for Disability Insurance Benefits-Religious Practitioner’s Certificate (DE 2502) Complete and sign the DE 2502 instead of Part D – Physician/Practitioner’s Certificate of the Claim for Disability Insurance (DI) Benefits (DE 2501) before sending it to us.
- For PFL: Practitioner’s Certification for Paid Family Leave (PFL) Benefits (DE 2502F) Complete and sign the DE 2502F instead of Part D – Physician/Practitioner’s Certificate of the Claim for Disability Insurance (DI) Benefits (DE 2501) before sending it to us.
Publications
- Physician/Practitioner’s Guide to Disability Insurance
- Licensed Health Professionals’ Guide to Paid Family Leave
- Tip Sheet: SDI Online Tips for Licensed Health Professionals
- DE 8516 - English
- Medical Examiner Information
Forms
- 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)
Follow these steps to submit your forms:
- 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.
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.
Publications
To order hard copies, use the Online Forms and Publications page.
- Disability Insurance Elective Coverage Pamphlet (Digital Version)
- DE 2565D English
- DE 2565D/S - Spanish
- DE 2565/A - Armenian
- DE 2565/CC – Traditional Chinese
- DE 2565/CM – Simplified Chinese
- DE 2565/K - Korean
- DE 2565/P - Punjabi
- DE 2565/T - Tagalog
- DE 2565/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
- DE 8714CF
- DE 8714CF/S - Spanish
- 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)
- DE 231SC
- DE 231SC/S - Spanish
Forms
Voluntary Plan Applications
- Application for Approval of Voluntary Plan Self-Insured Disability Benefits (DE 2520BV)
- Notice of Election to Make Voluntary Plan Applicable to All Employees (DE 2520CV)
- Application for Approval of Voluntary Plan for Successor (DE 2041)
- Application for Voluntary Plan Conversion (DE 2520MV)
- Application to Participate in a SBTPA Administered Voluntary Plan (DE 2520AU)
- Small-Business Third-Party Administrator Voluntary Plan Application (DE 2778)
Annual Plan Text Reports
Annual Financial Reports – Due Annually on February 15
- Annual Report of Self-Insured Voluntary Plan Transactions (DE 2568V) – For full functionality, this form must be downloaded to your computer before completing.
Security Deposit and Updates – Due Annually on April 15
- Voluntary Plan Security Review Worksheet (DE 2544SRW) – For full functionality, this form must be downloaded to your computer before completing.
- Guarantee Bond (DE 2544V)
- Agreement Regarding Deposit of Cash (DE 2545V)
- Guarantee Bond for a Small-Business Third Party Administrator (DE 2544VP)
- Model Letter of Credit (DE 2042) (Example)
Contact Forms – Due Annually on June 15
- Voluntary Plan Third-Party Administrator Authorization (DE 2520BV-A)
- Voluntary Plan Third-Party Administrator Administrative Changes (DE 2520BV-B)
- Voluntary Plan Employer Administrative Changes (DE 2520BV-C)
Claim Reporting Forms
- Report of Voluntary Plan Disability Claim (DE 2523)
- Report of Voluntary Plan Family Leave Claim (DE 2523F)
Claim Information
Tax Reporting
You can submit these forms online with e-Services for Business.
- Quarterly Contribution Return (DE 3D)
- Quarterly Contribution Return and Report of Wages (Continuation) (DE 9C)
- Voluntary Plan for Disability Insurance Quarterly Adjustment Form (DE 938)
- Instructions for Completing the DE 938i
Publications
- Employer’s Guide to Voluntary Plan Procedures (DE 2040)
- State Disability Insurance Bookmark (DE 8717DI)
- Instructions for Completing the Voluntary Plan for Disability Insurance Quarterly Adjustment Form (DE 938) (DE 938I)
General Release Letters
NDI is not automated. You must request and fill out paper forms to start your claim or extend the medical part of a claim.
Ask your personnel specialist or payroll officer to obtain the NDI claim forms DE 8501 and DE 8501F. Your employer must confirm your job status and complete Part A before you complete Part B. Contact us at 1-866-758-9768 to get medical extension forms.
Forms
- First Claim for Nonindustrial Disability Insurance (NDI) (PDF) (DE 8501)
- Claim for Nonindustrial Disability Insurance - Family Care Leave (NDI-FCL) (PDF) (DE 8501F)