DI / DE 8517-47

SAMPLE, this page for reference only.

NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 2168
STOCKTON CA 95201-2168
(866) 758-9768
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 claim for Non-Industrial Disability Insurance (NDI) has been disallowed from MM/DD/YY through MM/DD/YY because:

The scope of practice for nurse-midwives is limited to the treatment of normal pregnancy and childbirth. The individual who signed the medical portion of your claim has certified to a condition beyond the scope of his or her practice.

NOTE:
You may be eligible for benefits if you submit a new claim signed by a licensed physician or practitioner.
REASON FOR DETERMINATION:
Section 2708 California Unemployment Insurance Code (CUIC).

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 Non-Industrial Disability Insurance (NDI) Claim should include your Social Security Number and be addressed to the office shown above.

State of California / Employment Development Department (EDD)

DE 8517-47 (03/48) (INTRANET)