DI / DE 2517-36

SAMPLE, this page for reference only

DISABILITY INSURANCE
PO BOX 00000
SACRAMENTO CA 99999-9999
FIRSTNAME M LASTNAME
‎1234 ANY ST
ANY CITY CA 99999-9999
 

NOTICE OF DETERMINATION

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
YOUR STATE DISABILITY BENEFIT RATE HAS BEEN REDUCED FOR THE PERIOD BEGINNING MM/DD/YY THROUGH MM/DD/YY BECAUSE OUR RECORDS INDICATE THAT YOU ARE ENTITLED TO SIMULTANEOUS COVERAGE UNDER A VOLUNTARY PLAN(S) (VP) FOR THE SAME PERIOD. SECTION  3253-1, TITLE 22, CALIFORNIA CODE OF REGULATIONS (CCR).
This determination is final unless you file an appeal within thirty (30) days from the mailing of this notification. You may appeal by giving a detailed statement as to why you believe the determination is in error. All communications regarding this Disability Insurance (DI) Claim should include your Social Security Number addressed to the office shown above.

State of California / Employment Development Department (EDD)

DE 2517-36 Rev. 3 (03-18) (INTRANET)