DI / DE 2578

SAMPLE, this page for reference only.

DISABILITY INSURANCE
PO BOX 00000
THE CITY CA 99999-9999
Mailing Date:
MM/DD/YYYY
RETURN TO: 
DISABILITY INSURANCE
PO BOX 989478
WEST SACRAMENTO CA 95798-9478
 
FIRSTNAME M LASTNAME
1234 SAMPLE ST APT 4321
MY CITY ST 99999-9999

WORKERS' COMPENSATION INFORMATION REQUEST

EDD Customer Account Number CLAIM ID SSN/ECN CED
Blank space Blank space Blank space MM/DD/YYYY

For faster processing, you may complete and submit this form online at www.edd.ca.gov If this form is submitted online, you do not have to mail this form back to the Employment Development Department (EDD). When completing this form, PLEASE PRINT WITH BLACK INK

Your claim for Disability Insurance (DI) indicates your disability was caused by your work. Disability Insurance benefits are usually not payable if you are eligible for Workers' Compensation benefits through your employer or your employer's insurance company. In order that your eligibility may be determined, you must answer the questions below. THIS INFORMATION IS NECESSARY TO PROCESS YOUR CLAIM. PLEASE REPLY WITHIN 5 DAYS.

  1. Was your disability caused or aggravated by your work?
    1. If you answered "NO", it is not necessary to complete items 2 through 9. Sign and date the form in item 10 attesting to the following statement: "My disability was not caused by my work and I am not claiming Workers' Compensation benefits through my employer or its Workers' Compensation insurance company. If I am paid any money for Workers' Compensation for the period I am claiming Disability Insurance (DI), I will notify the Employment Development Department (EDD) immediately."
    2. If you answered "YES," above, complete items 2 through 9 before signing and dating the form in item 10.
    3. Blank line
  2. What was the date of the injury or illness which caused your disability?
    1. Blank line
  3. Explain in detail on a separate sheet of paper how your disability occurred.
  4. Have you notified your employer?
  5. Are you now or have you been paid Workers' Compensation temporary disability?
    1. If "YES," for what period Blank line
    2. Weekly rate $ Blank line

DE 2578 Rev. 2 (3-12) (INTRANET)

SAMPLE, this page for reference only.

For Official Use Only
EDDCAN
Blank line
CLAIM ID
Blank line
SSN/ECN
Blank line
CED
MM/DD/YYYY
 
  1. Has your claim for Workers' Compensation been denied:
  2. Name and address of the Worker's Compensation insurance company:
    1. Blank line ZIP CODE
  3. Have you applied to the Workers' Compensation Appeals Board?
    1. If "YES," the EAMS ADJ case number is Blank line
  4. If you have an attorney who will represent you before the Workers' Compensation Appeals Board, enter his/her name and address below:
    1. Name of Attorney: Blank line Phone:Blank line
    2. Address:Blank line
  5. The above statements are to the best of my knowledge and belief, true, correct and complete.
Blank line
SIGNATURE
 
Blank line
 DATE 
 

DE 2578 Rev. 2 (3-12) (INTRANET)