Disability Insurance Elective Coverage Forms and Publications

Please use the links on this page to access informational forms, materials, and the application for Disability Insurance Elective Coverage.

Forms

• Use a Computer to Fill In Forms
  • 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)

Publications

• Disability Insurance Elective Coverage Pamphlet
  • DE 2565 Rev. 14 (1-12) - English
  • DE 2565/S Rev. 14 (1-12) - Spanish
• Disability Insurance Elective Coverage (DIEC) Rate Notice and Instructions for Computing Annual Premiums
  • DE 3DI-I Rev. 54 (12-12)
• Information Sheet
  • Elective Coverage for Employers and Self-Employed Individuals - DE 231EC Rev. 8 (6-09)
• 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)
• Fact Sheets
  • Disability Insurance Elective Coverage Program Fact Sheet - DE 8714CC Rev. 19 (12-11) - English
  • Disability Insurance Elective Coverage Program Fact Sheet - DE 8714CC/S Rev. 19 (8-12) - Spanish

You can order, view, print, and/or download forms on the Online Forms and Publications page.