DI / DE 2599

SAMPLE, this page for reference only

 

Explanation of Benefit Payment Record

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In response to your request for payment information, see the attached copy of the computer record of your Disability Insurance (DI), Paid Family Leave (PFL), or Non-Industrial Insurance (NDI) claim payments. To help you better understand this computer record, the following explanation is provided.

The top portion of the record may include the following information:

EDDCAN:  Employment Development Department Customer Account Number
SSN:  Social Security number
DBA:  Daily Benefit Amount
BAL:  Balance remaining in this account
AMT PD:  Amount of benefits paid
WBA: Weekly Benefit Amount (WBA)
PD DAYS:  Number of days paid
DURC:  Duration code showing the estimated end of disability, need for family care, or bonding benefits
CLAIM ID:  Claim Identification Number
CLAIM EFFECTIVE DATE/CED:  Beginning date of the claim
MBA:  Maximum Benefit Amount (MBA)
DAYS DISQ:  Number of days disqualified

The second section of the record, which begins with “ACT” or “action”, will show what action has been taken on the claim. The first column, under “ACT” or “action”, gives the action code:

A:  Adjustment
B:  Blockout
D:  Disqualification
E:  Erroneous
F:  Form
I:  Inactivation
L:  Benefit reduction
N:  New or replacement
O:  Overpayment
P:  Payment
Q:  Qualification
R:  Redetermination
S:  Suspend
T:  Autopay
U:  Unsuspend
V:  Payment to voluntary plan (VP)
W:  Waiting period

Additional information about the action taken is shown to the right of the action code:

START DT/START DATE:
The beginning date of the action.
END DT/END DATE:
The ending date of the action. When “999999” is shown as the ending date, it means an undetermined future date, or “until eligible.”
NUM DYS/NUMBER OF DAYS:
Number of days included in the action.
AMT/AMOUNT:
Amount of the benefit payment, or the amount of the benefit reduction.
ISS DT/ISSUE DATE:
The date the benefit payment was issued, or the date the action was taken.
STS/STATUS:
Benefit payment:
01-  not cashed
02-  cashed
06-  lost or stolen
07-  cancelled
08-  forged
11-  expired
E2-  debit card payment
EX-  new payment

If you have any questions after reading this form, call ‎1-800-480-3287 for DI claims,‎1-877-238-4373 for PFL claims, and ‎1-866-758-9768 for NDI claims. TTY (non-voice) access (for deaf and hearing-impaired persons only) is available at ‎1-800-563-2441 for DI and ‎1-800-445-1312 for PFL claims.

If you need information regarding an Unemployment Insurance (UI) claim, please call:‎1-800-300-5616

DE 2599 Rev.9 (4-21) (INTRANET)