Disability Insurance – Elective Coverage Forms and Publications

Use the links on this page to access informational forms, materials, and the application for Disability Insurance Elective Coverage. The following documents are PDFs.


Some forms have been prepared so that you can fill in the blanks using a computer. To complete forms, you may need to download and save them on the computer, then open them with the no-cost Adobe Reader.

Note: You are reporting confidential information on these forms. Do not use email or other unsecure methods of communication to send these forms to the EDD.


  1. Select the form you need. (If you receive a “pop up” box at the bottom of your browser, select Open.) If it does not open automatically in Adobe Reader, download and save it on the computer, then open it with Adobe Reader.
  2. Enter your data into the fields as directed in the form.
  3. Print two copies of the form, one for your records and one to mail to the EDD. (If you have Acrobat 3.0 or greater, you can save the data on the form for future use.)


  • Disability Insurance Elective Coverage Pamphlet
  • Disability Insurance Elective Coverage (DIEC) Rate Notice and Instructions for Computing Annual Premiums
  • Information Sheet: Elective Coverage for Employers and Self-Employed Individuals
  • 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
  • Fact Sheet: Disability Insurance Elective Coverage Program Fact Sheet
  • State Disability Insurance Bookmark

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