DI / DE 1869

SAMPLE, this page for reference only

DISABILITY INSURANCE
P.O. BOX 8190
CHICO, CA 95927-8190

RETURN TO :

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Mailing Date:
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Claim Effective Date:
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Claim ID:
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For Office Use Only:
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SELF EMPLOYMENT QUESTIONNAIRE

You recently filed a claim for either Disability Insurance (DI) or Paid Family Leave (PFL). To avoid possible loss of benefits, you must complete and return this questionnaire within seven (7) calendar days. A self-addressed courtesy reply envelope is enclosed for your convenience.

NOTICE: All items must be answered or marked "Unknown" or "Does not apply." If the spaces provided are not adequate, attach additional sheets as necessary. If you need help in completing this form, you may visit or write your local SDI Office or log on to our Web site at http://edd.ca.gov/Disability/Self-Employed.htm, or you may call us toll-free at ‎1-800-480-3287 For PFL, call ‎1-877-238-4373 For SDI for State Employees, call ‎1-866-352-7675
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NAME OF MOST RECENT EMPLOYERBlank space TELEPHONEBlank space
ADDRESS OF MOST RECENT EMPLOYERBlank space
1. Why did you leave this employment?Blank space 2. On what date did you become self-employed?Blank space
3. Why did you become self-employed?Blank space
4. Was it your intent to become self-employed or was it for stop-gap employment purposes?Blank space
5. Are you still self-employed?
6. What is the name and address of your business?
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Name
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Address
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City
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State
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Zip Code
7. Type of Business:
 

DE 1869 Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only

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8 Please describe the services you performBlank space
9 How are you paid for the services you perform? (E.g, commission, hour, job, piece, etc.) Blank space
10 Are any payroll tax deductions made from the monies paid to you? If yes, explainBlank space
11Have you applied for Disability Insurance (DI) Elective Coverage?
12 While self-employed, have you worked or looked for work as a regular employee? If yes, please provide the names, addresses, and phone numbers of the employers and the date you contacted them.
Name Address Telephone Number Date
Blank space Blank space Blank space Blank space
Blank space Blank space Blank space Blank space
Blank space Blank space Blank space Blank space

I certify under penalty of perjury that to the best of my knowledge the foregoing is true and correct.

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Signature
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Phone Number
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Date

DE 1869 Rev. 2 (11-21) (INTRANET)