DI / DE 8517-17

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:

Your condition is not covered under "disability" as listed below.

"Disability" or "disabled" includes mental or physical illness and mental or physical injury, including any illness or injury resulting from pregnancy, childbirth, or related medical condition. An employee is deemed disabled on any day in which, because of his or her physical, mental, or medical condition, he or she is unable to perform his or her regular or customary work.

REASON FOR DETERMINATION:

Section ‎19878(c) 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 8517-17 (03/18) (INTRANET)