DI / DE 8517-16

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:

Disability benefits have been or will be reduced by the amount of cash payments you have received or are entitled to receive, as temporary disability indemnity under a workers’ compensation law or employer’s liability law.

REASON FOR DETERMINATION:

Section 19882 California Government 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 8517-16 (03/18) (INTRANET)