DI / DE 8500

SAMPLE, this page for reference only.

NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 2168
STOCKTON CA 95201-2168
RETURN TO: 
NONINDUSTRIAL DISABILITY INSURANCE PO BOX 2168 STOCKTON CA 95201-2168
FIRSTNAME LASTNAME
‎1234 SAMPLE ST
ANY CITY CA 99999-9999
 

NOTICE OF ELIGIBILITY FOR NON-INDUSTRIAL DISABILITY INSURANCE (NDI) OR NON-INDUSTRIAL DISABILITY INSURANCE (NDI) - FAMILY CARE LEAVE ‎(NDI-FCL)

SSN:
‎XXX-XX-0000
UNIT NUMBER:
999
MAILING DATE:
MM/DD/YY
CLAIM EFFECTIVE DATE:
MM/DD/YY
You are entitled to benefits within the period MM/DD/YY to (not including) MM/DD/YY. (For ‎NDI-FCL you are allowed a maximum of 42 days in the above period.) For ‎NDI-FCL claimants: You must notify your employer the days you will take for Family Care Leave.
If you recover or return to work ON or BEFORE MM/DD/YY, enter that date here Blank Line_________________ sign, date and return this form immediately.
Sign your name
Blank line 
Date
Blank line 
YOU MUST NOTIFY THE EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD) IF YOU:
  • Decide to receive your accrued vacation pay and have not already advised the Department.
  • File a claim for, or receive workers compensation or industrial disability leave.
  • Retire or terminate your employment with the State while receiving NDI payments.
NOTE:
Your "voluntary" payroll deductions such as health benefit plans, credit union loans, etc, will be deducted from your disability payments unless you cancel them. Although the NDI checks are issued by the California State Controller’s office, the payments are processed through your Department’s personnel or payroll office based on the authorization of the Employment Development Department (EDD).
Questions regarding payments or the changing of "voluntary" deductions should be directed to your personnel or payroll office.
Be sure to include your social security account number on all correspondence to the Employment Development Department (EDD).

State of California/Employment Development Department (EDD)

DE 8500 Rev. 3 (10-21) (INTRANET)