DI / DE 2475

SAMPLE, this page for reference only

GUIDE FOR COMPLETING A CLAIM FORM FOR PAID FAMILY LEAVE (PFL) BENEFITS

State Disability Insurance (SDI) offers secure and convenient online options for filing Paid Family Leave (PFL) claims. For faster processing, submit a claim form and documentation on SDI Online(edd.ca.gov/SDI_Online).
To avoid delays when filing a claim using the paper application, please follow the general guidelines below. Allow sufficient time for claim processing (generally two weeks). For more information, read the yellow instruction and information sheet provided with the Claim for Paid Family Leave (PFL) Benefits (DE 2501F) contact the PFL office at ‎1-877-238-4373, or visit State Disability Insurance (edd.ca.gov/disability).
Claim Type
PFL provides benefits to eligible workers who need to take time off work to care for a seriously ill family member, to bond with a new child, or to participate in a qualifying event as a result of a family member’s military deployment to a foreign country. Do not file for more than one claim type on the same claim form or for the same period of time.
Bonding with a New Baby after a Disability Insurance (DI) Pregnancy-Related Claim
For new mothers who received pregnancy-related DI benefits prior to filing for PFL benefits.
  • The Claim for Paid Family Leave (PFL) Benefits – New Mother (DE 2501FP) will automatically be mailed to you in a separate envelope at the end of your DI claim after your final payment is issued.
  • When you have recovered from delivering your baby, submit your Claim for Paid Family Leave (PFL) Benefits – New Mother (DE 2501FP).
  • Complete all sections of the Claim for Paid Family Leave (PFL) Benefits – New Mother (DE 2501FP), and mail no later than 41 days from the date you wish to begin your bonding claim or you may submit it using SDI Online.
  • If you do not receive this form, call DI at ‎1-800-480-3287 or PFL at ‎1-877-238-4373.
Bonding with a New Child
For new mothers without a prior pregnancy-related disability claim, new fathers, registered domestic partners, or foster care or adoptive parents.
  • Complete and sign Part A on page 1 and Part B on page 3 of the Claim for Paid Family Leave (PFL) Benefits (DE 2501F), and mail no later than 41 days from the date you wish to begin your bonding claim.
  • Include Proof of Relationship documentation with your bonding claim.
    • Birth verification must clearly show the child’s name, date of birth, gender, and the name of the parent claiming benefits.
    • New placement of foster care or adoption documentation must verify the date the child was placed in your custody.
  • Bonding benefits are payable within one year of the child’s birth or placement, if eligible.
Care
To provide care for a seriously ill child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner.
  • Submit a Claim for Paid Family Leave (PFL) Benefits (DE 2501F):
    • Complete and sign Part A on page 1.
    • Have the care recipient complete Part C on page 3.
    • Have the care recipient’s physician/practitioner complete and sign Part D on page 4.
  • If the care recipient cannot complete and sign Part C on page 3 due to their disability, or if you are an authorized representative filing for benefits on behalf of an incapacitated or deceased claimant, call ‎1-877-238-4373 for instructions and required forms prior to submitting a claim. Parts A, C, and D are required to be considered a complete claim.

DE 2475 Rev. 10 (12-20) (INTRANET)

SAMPLE, this page for reference only

Military Assist
To participate in a qualifying event as a result of a spouse, registered domestic partner, parent, or child’s military deployment to a foreign country.
  • Complete and sign Part A on page 1 and Part E on pages 5 and 6 of the Claim for Paid Family Leave (PFL) Benefits (DE 2501F), and mail no later than 41 days from the date you wish to begin your military assist claim.
  • Proof of covered active duty or call to covered active duty of the family member (listed in Box E10) must be attached along with documentation that supports the qualifying event for leave.
Partial Benefits
If you have reduced your work schedule and have a wage loss.
  • Please mark “yes” on the Claim for Paid Family Leave (PFL) Benefits (DE 2501F), question A13 or on the Claim for Paid Family Leave (PFL) Benefits – New Mother, (DE 2501FP), question 6 if you continue to work during your family care leave.
  • Attach a separate letter if you will be working part-time or taking leave on an intermittent basis. Be sure to include your Social Security number, name, address, phone number, regular working hours, rate of pay, and the amount of time you plan to be off work each week.
Wages from your Employer
If your employer continues to pay you wages during your claim.
If your employer pays you the difference between PFL benefits and full pay, write “integrate” on the Claim for Paid Family Leave (PFL) Benefits (DE 2501F), question A22 or on the Claim for Paid Family Leave (PFL) Benefits – New Mother(DE 2501FP), question 6.
Your Responsibilities
Submit your claim and any other required forms completely, accurately, and in a timely manner.
  • Use black ink only.
  • Do not separate the pages of the form, and submit all parts of the claim form at one time.
  • Submit the claim form when you begin your family leave claim. The EDD is unable to process claims with future beginning dates.
  • If submitting a claim form late, you must include a written explanation of the reason(s) for the lateness to avoid a disqualification.
  • Mail your claim form in the pre-addressed envelope. If you do not have the pre addressed envelope provided with the claim, send your claim and correspondence to: EDD-Paid Family Leave, PO Box 989315, West Sacramento, CA 95798-9315.
PFL Toll-Free Numbers
English:
1-877-238-4373
Spanish:
1-877-379-3819
Cantonese:
1-866-692-5595
Vietnamese:
1-866-692-5596
Armenian:
1-866-627-1567
Punjabi:
1-866-627-1568
Tagalog:
1-866-627-1569
For additional information, please visit State Disability Insurance (edd.ca.gov/disability).
The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling ‎1-866-490-8879 (voice) or through the California Relay Service at 711.
These guidelines are for general information only and do not have the force and effect of law, rule, or regulation.

DE 2475 Rev. 10 (12-20) (INTRANET)