Disability Insurance - Forms and Publications

En Español

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Forms

• Use a Computer to Fill In Forms
  • Claim for Disability Insurance (DI) Benefits - DE 2501 Rev. 77 (3-06)
    The online version of the DE 2501 may be filled-in and printed. To order claim forms, use the Request A Claim Form for Disability Insurance Benefits or call 1-800-480-3287 or 1-866-658-8846 (En Español).
  • 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.
• Request for Continued Benefits - Physician’s Supplementary Certificate DE 2525XXB Rev. 3 (1-12)
  If you will be disabled beyond the original period established on your claim, have your doctor complete and submit the DE 2525XXB to the Disability Insurance Office that processed the claim or call
  1-800-480-3287 or 1-866-658-8846 (En Español).
• 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. 39 (11-08) - English
  • DE 1857A/C/ - Rev. 39 (11-08) - Chinese
  • DE 1857A/S/ - Rev. 39 (11-08) - Spanish
  • DE 1857A/V/ - Rev. 39 (11-08) - 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 - Facsimile and Instructions - Spanish
  • DE 2501/S - Rev. 77 (3-06)
• Disability Insurance Provisions (For Disabilities Beginning on or After January 1, 2003) - Bulk orders (25 or more) see Internet Order Form
  • DE 2515 - Rev. 59 (1-12) - English
  • DE 2515/S - Rev. 59 (1-12) - Spanish
• The Medical Provider’s Guide to DI
  • DE 2548 - Rev. 4 (3-11)
• Disability Insurance Elective Coverage - Bulk orders (25 or more) see Internet Order Form
  • 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. 7 (1-12)
• Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts in Dollar Increments
  • DE 2589 - Rev. 4 (1-12)
• Fact Sheets
  • Disability Insurance Program - DE 8714C - Rev. 35 (12-11) - English
  • Disability Insurance Program - DE 8714C/S - Rev. 35 (12-11) - Spanish
  • Disability Insurance Elective Coverage Program - DE 8714CC - Rev. 19 (12-11) - English
  • Disability Insurance Elective Coverage Program - DE 8714CC/S - Rev. 19 (12-11) - Spanish

Paid Family Leave Insurance Forms and Publications