DI / DE 8517-19

SAMPLE, this page for reference only

NONINDUSTRIAL DISABILITY INSURANCE
PO BOX 0000
STOCKTON CA 99999-9999
‎(000) 000-0000
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 Non-Industrial Disability Insurance (NDI) has been disallowed beginning MM/DD/YY through MM/DD/YY. The beginning date of your claim has been adjusted for the following reason:

Your claim was not filed within 49 days of the beginning of your disability.

REASON FOR DETERMINATION:

Section 2706.1 Unemployment Insurance (UI) Code.

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 Non-Industrial Disability Insurance (NDI) Claim should include your Social Security Number and be addressed to the office shown above.

State of California/Employment Development Department (EDD)

DE 8517-19 (03/18) (INTRANET)