DI / DE 2517-18

SAMPLE, this page for reference only.

DISABILITY INSURANCE
PO BOX 00000
SACRAMENTO CA 99999-9999
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 Disability Insurance (DI) Benefits has been denied from MM/DD/YY through MM/DD/YY The beginning date (claim effective date) of your claim has been adjusted because:
The beginning date cannot be more than 7 days before the first date you were examined by or under the care of a physician or practitioner. (Basis: section ‎2706-1(a), TITLE 22, of the California code of regulations (CCR) )
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 Disability Insurance (DI) Claim should include your Social Security Number addressed to the office shown above.

State of California / Employment Development Department (EDD)

DE 2517-18 Rev. 3 (03-18) (INTRANET)