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Notice of Claim Error

We are unable to process the BlankLine claim you signed on BlankLine , because:

1. 1 You did not provide a Social Security number, EDD Client Number (ECN), or number used to report wages or Tax ID on your claim.
2. 2 Your claim was submitted without a completed physician or practitioner's certificate.
3. 3 The following signatures are missing from your claim. Rubber-stamped, electronic, and digital signatures are not acceptable.
   1. a The "Declaration and Signature" section must be signed by you or your authorized representative.
   2. b The "Health Insurance Portability and Accountability Act Authorization" must be signed by you or your authorized representative.
   3. c The "Statement of Care Recipient" must be signed by the care recipient or their authorized representative.
   4. d The "Authorization for Disclosure of Personal-Health Information" must be signed by the care recipient or their authorized representative.
4. 4 Other: Blank Line

Your claim cannot be processed until you complete the items checked above. The completed form should be returned immediately, but no later than 10 days from the date of mailing shown above. No further action can be taken until your claim is returned.

Attach this notice to your completed claim when you return it to us.

1. 5 We received your State Disability Insurance (SDI) claim before your requested Claim Effective Date (CED). You may resubmit your claim seven days after that date.
2. 6 You were not disabled at the time you filed your claim. If you are now disabled, or when you become disabled, you may complete and file an Application for State Disability Insurance (SDI) Benefits.
3. 7 Your claim was submitted on the wrong form. We have enclosed the correct form for you to resubmit your claim.
4. 8 We received your Paid Family Leave (PFL) claim more than seven days before your requested Claim Effective Date (CED). You must submit a new claim with the form enclosed and with current information no more than 7 days before and not more than 41 days after the date you wish your claim to begin.
5. 9 An "Application for Paid Family Leave (PFL) Benefits - Bonding for New Mother" form is being sent to you under separate cover. Follow the instructions provided on that form for completion and return.

All communications regarding this claim must include your Social Security number, EDD Client number, number used to report wages or Tax ID and be sent to the address shown below. If you have any questions or need assistance, please call Blank Line .

DE 2535 Rev. 7 (7-24) (INTRANET)