Disability Insurance - Forms and Publications

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Disability Insurance - Forms and Publications

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Forms

(publications are listed separately below)

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).
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)

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

(forms are listed separately above)

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. 56 (11-08) - English
- DE 2515/S - Rev. 56 (11-08) - Spanish
The Medical Provider’s Guide to DI
- DE 2548 - Rev. 3 (5-07)
Disability Insurance Elective Coverage - Bulk orders (25 or more) see Internet Order Form
- DE 2565 - Rev. 12 (1-09) - English
- DE 2565/S - Rev. 12 (1-09) - Spanish
Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts
- DE 2588 - Rev. 5 (1-09)
Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts in Dollar Increments
- DE 2589 - Rev. 2 (1-09)
Fact Sheets
- Disability Insurance Program - DE 8714C - Rev. 32 (1-09) - English
- Disability Insurance Program - DE 8714C/S - Rev. 32 (1-09) - Spanish
- Disability Insurance Elective Coverage Program - DE 8714CC - Rev. 16 (1-09) - English
- Disability Insurance Elective Coverage Program - DE 8714CC/S - Rev. 16 (1-09) - Spanish

Paid Family Leave Insurance Forms and Publications