DI / DE 8517-02

SAMPLE, this page for reference only

NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 0000
STOCKTON CA 99999-9999
‎(000) 000-0000
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 medical certificate does not indicate that you were examined by or under the care of a physician during the period you are claiming benefits.

REASON FOR DETERMINATION:

Section 2706-1 (c) of Title 22 of the California Administration Code.

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 8517-02 (03/18) (INTRANET)