How to File a Disability Insurance Claim by Mail

You can get a paper Claim for Disability Insurance (DI) Benefits (DE 2501) form by:

• Ordering a form online to have it mailed to you.
• Getting the form from your licensed health professional or employer.
• Visiting an SDI Office.
• Calling 1-800-480-3287 and selecting DI Information option 3 to request a paper form by mail.

Note: Allow up to ten days to receive this form.

You must provide the following information to file a DI claim:

• First and last name.
• Most current employer’s business name, phone number, and mailing address (as stated on your W-2 or paystub).
• Last date you worked your normal or usual duties (or the date you began working less than full or modified duty).

You must also give the following information only if it applies to you:

• Any wages you received or expect to receive from your employer (sick leave, paid time off (PTO), vacation pay, annual leave, and wages earned after you stopped working).
• Any workers’ compensation claim information.
• If you receive in-patient treatment at an alcohol recovery home or drug-free rehabilitation facility, provide the name, address, and phone number of the home or facility.

Note: The facility must be licensed and certified by the state in which the facility is located.

You are responsible for filling out Part A - Claimant’s Statement of the DE 2501 form. Write clearly in the spaces provided. Fill out the form completely using black ink only, and sign the form. An incomplete form could delay processing.

You must get a licensed health professional certification for your disability. Once you have filled out Part A of the DE 2501 form, contact your licensed health professional about completing, signing, and submitting your medical certification (Part B – Physician/professional’s Certificate).

Talk to your licensed health professional about their process for submitting a DI claim (not all of them follow the same process). Your licensed health professional must submit the certification no later than 49 days after your disability begins or you may lose benefits.

• If your licensed health professional wants to submit the medical certification using SDI Online, allow 14 calendar days for us to receive and process your claim.
• After your claim has been received, your licensed health professional can find your claim in SDI Online.

There are two parts to completing this form. For your claim to be considered complete, both parts of the DE 2501 form need to be submitted:

• Part A - Claimant’s Statement
• Part B - Physician/professional’s Medical Certificate (a licensed health professional can submit this part)

You can file your claim on the first day of your disability, but to avoid creating delays on your claim, losing benefits, or having your claim disqualified, you should file your claim:

• No earlier than nine days after your disability begins.
• No later than 49 days after your disability begins

If you have a good reason for filing late, please provide that explanation when you file your claim so the claims analyst can review your information to make a determination.

Your claim will not be processed until we receive both part A and part B.

Use the pre-addressed envelope to mail to:

State of California
Employment Development Department
PO Box 989777
West Sacramento, CA 95798-9777

Do not submit the same claim more than once. This will delay your claim.

Note: Your employer will be notified that you have submitted a DI claim. However, medical information is confidential and will not be shared with your employer.