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PLAN FAMILY LEAVE CLAIM, DE 2523F. CLAIMANT INFORMATION COMPLETE ITEMS 1 10 AND 16 18. SUBMIT WITHIN 15 DAYS AFTER RECEIPT OF A FIRST CLAIM FOR DISABILITY BENEFITS. 1. SOCIAL SECURITY NUMBER 2. CLAIMANT S NAME (FIRST, MIDDLE, LAST) 3. DATE DISABILITY BEGAN 4. CLAIMANT S MAILING ADDRESS STREET/PO BOX 5. SEX MALE CITY STATE 6. DATE OF BIRTH ZIP CODE / MM 7. VOLUNTARY PLAN NUMBER FEMALE / DD YYYY 8. VOLUNTARY PLAN EMPLOYER NAME 9. DIAGNOSIS OR INTERNATION.

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If you are on automatic payment, you will receive a Disability Claim Continued Eligibility Questionnaire (DE 2593) after 10 weeks of payment. You must return this form to us to certify that your disability continues. Your benefits will stop if you do not complete and return the DE 2593.

To be eligible for permanent disability benefits in California, your doctor must write a report saying that your recovery has reached a plateau and that you aren't likely to get better in the next year, even with further medical treatment.

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

Hours: 8 a.m. to 5 p.m. (Pacific time), Monday through Friday, except on state holidays. Note: Monday morning before 10 a.m. is our busiest call time, so we recommend calling at other times.

Once we receive your completed claim application, we will determine your eligibility. You can expect this process to take up to 14 days. Note: Processing time may vary depending upon the claim. If your claim is incomplete or requires additional information, confirming eligibility can be delayed.

For Disability Insurance claims, fill out and sign Part B – Physician/Practitioner's Certificate on the Claim for Disability Insurance (DI) Benefits (DE 2501) form. Mail it in within 49 days from the date your patient's disability begins.

What form does my doctor have to fill out for disability in California? For Disability Insurance claims, fill out and sign Part B Physician/Practitioner's Certificate on the Claim for Disability Insurance (DI) Benefits (DE 2501) form. Mail it in within 49 days from the date your patient's disability begins.

Downloading and Printing The forms are in Portable Document Format (PDF). You may need to download the no-cost Adobe Reader to view and print linked documents.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232