Disability Insurance - Use a Computer to Fill in Forms

Some EDD forms have been prepared to allow customers to fill in the blanks with their personal computers. The forms are in the PDF format and you will need the Acrobat Reader or Acrobat 3.0 or greater to enter data, view, and print the forms.

You may need to download the free Adobe Reader to view and print linked documents.

Note: You are reporting confidential information to EDD on these forms. Do not use e-mail or other unsecured methods of communication to send forms to EDD.

Download the form that you want to use. Load it into the Acrobat Reader. Your cursor will blink in the first field. Just key your data into the field. You can tab to the next field until the form is completed. If you are using the Acrobat Reader, you cannot save your data, so you will need to print a copy for your records and one to mail to EDD. If you have Acrobat 3.0 or greater, you can save the data on the form for future use.

• Claim for Disability Insurance (DI) Benefits
  • DE 2501 - Rev. 77 (3-06)
  • Nurse Practitioner Certification for Paid Family Leave Benefits, DE 2509A
    (The DE 2509A must accompany the Claim for Disability Insurance Benefits (DE 2501), if a nurse practitioner is certifying the Claim for Disability Insurance Benefits for a disability other than a normal pregnancy or childbirth.)
• Request for Continued Benefits - Physician’s Supplementary Certificate DE 2525XXB
  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. 41 (2-05)