DI / DE 8517-21

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 CLAIM DATE ADJUSTMENT

 
MAILING DATE:
MM/DD/YY
CLAIM EFFECTIVE DATE:
MM/DD/YY

Your first claim for Non-industrial Disability Insurance (NDI) has been disallowed beginning MM/DD/YY through MM/DD/YY. The beginning date of your claim has been adjusted for the following reason:

The beginning date cannot be more than seven days before the first date you were examined by or under the care of the doctor or practitioner who completed your claim form.

REASON FOR DETERMINATION:

Section 2706-1(a), Title 22 California Administrative 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 8517-21 (03/18) (INTRANET)