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EDD Employment Development Department State of California Logo

Full Coverage Referral to Voluntary Paid Family Leave Plan

Referral Date:

Blank Line

Plan Number:

Blank Line

Employer:

Blank Line

Blank Box

Claim Information:

Last four digits of Social Security number:Blank Space

Claimant's Full Name:Blank Space

Effective Date of Claim:Blank Space

Date Family Leave Began:Blank Space

PFL Maximum Benefit Amount:Blank Space

Paid Family Leave (PFL) Weekly Benefit Rate: Blank Space

We are forwarding the attached claim records under the provisions of California Unemployment Insurance Code (CUIC), section 2712 Our information indicates that your voluntary plan is liable for coverage of this claim. Please use the "Reply Copy" of this form to promptly notify us if this claimant is covered under your voluntary plan. If you deny liability, please provide your reasons and notify the claimant of your decision.

If we do not receive your response by Blank line, we will assume a denial and will appeal to an administrative law judge (ALJ) to determine liability. If you concede liability after this date, please contact our office before you commence payments because you may be expected to reimburse the Employment Development Department (EDD) for benefits paid.

The benefit information shown above was calculated using a claim date that complies with PFL eligibility requirements. If you accept liability and use a different claim date, you may need to request alternate benefit information from our office.

To date, the EDD has paid no benefits on this claim.

To date, the EDD has paid Blank line in benefits for the period of Blank line through Blank line.

We have enclosed information regarding a potentially related pregnancy claim for State Disability Insurance benefits.

We have enclosed information regarding a prior PFL claim(s) within the previous 12 months.

Our records show this claimant filed a disability or family care leave claim with a voluntary plan within the past 12 months. The claimant can provide additional information.

Some claim information is not provided because we do not have the required consent for release from the claimant and/or the care recipient.

Paid Family Leave Office PO Box 45011 Fresno, CA 93718-5011 Phone:Blank Space

Original

DE 5022F Rev. 4 (9-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Full Coverage Referral to Voluntary Paid Family Leave Plan

Referral Date:

Blank Line

Plan Number:

Blank Line

Employer:

Blank Line

Blank Box

Claim Information:

Last four digits of Social Security number:Blank Space

Claimant's Full Name:Blank Space

Effective Date of Claim:Blank Space

Date Family Leave Began:Blank Space

PFL Maximum Benefit Amount:Blank Space

Paid Family Leave (PFL) Weekly Benefit Rate:Blank Space

Reply to:

Paid Family Leave Office
PO Box 45011
Fresno, CA 93718-5011
Fax: ‎1-916-319-1090

Please check all the applicable boxes:

We accept full liability for the above-described claim and will determine if the claimant is eligible to receive benefits under the Voluntary Plan.

We will reimburse the Employment Development Department, as requested, in the amount of Blank line.

We have paid benefits on this claim. Please indicate date paid Blank line and amount Blank line.

We do not accept full liability, but we do accept simultaneous liability for the above-described claim because: Blank line
Blank line

We deny liability for the above-described claim because (please provide explanation and denial letter/supporting documents): Blank line
Blank line

Employee quit date: Blank line Employee termination date: Blank line

Print Name: Blank line

Signature: Blank line

Phone: Blank line

Ext: Blank line

Date: Blank line

Reply Copy

DE 5022F Rev. 4 (9-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Full Coverage Referral to Voluntary Paid Family Leave Plan

Referral Date:

Blank Line

Plan Number:

Blank Line

Employer:

Blank Line

Blank Box

Claim Information:

Claimant's Full Name:Blank Space

Date Family Leave Began:Blank Space

Effective Date of Claim:Blank Space

Paid Family Leave (PFL) Weekly Benefit Rate:Blank Space

PFL Maximum Benefit Amount:Blank Space

We have received your claim for PFL benefits, but our records indicate that you were covered by your employer's voluntary plan when your family leave began. We have, therefore, sent your claim to your employer's plan with a request that they pay you any benefits to which you are entitled under that plan. We will advise you when we receive a response from them. If your employer's plan denies liability for your claim, the Employment Development Department (EDD) will pay you the benefits to which you are entitled and resolve any liability dispute with your employer's plan.

You should provide any additional information your employer's plan requests to ensure prompt action on your claim. If you receive any family leave benefits from your employer's plan before hearing from us, please notify our office immediately. Please include your Social Security number on all correspondence.

The information above shows the amount of benefits we will pay you if it is decided that the EDD is liable. If, however, it is decided that your employer's plan is liable, it must pay you at least these amounts. If your employer's plan uses a different effective date of claim, these benefit amounts may change.

Paid Family Leave Office PO Box 45011 Fresno, CA 93718-5011 Phone: Blank Space

Claimant Copy

DE 5022F Rev. 4 (9-21) (INTRANET)

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DI / DE 5022F

Full Coverage Referral to Voluntary Paid Family Leave Plan

Full Coverage Referral to Voluntary Paid Family Leave Plan

Full Coverage Referral to Voluntary Paid Family Leave Plan