DI / DE 2517-19

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) 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 CANNOT BEGIN BEFORE THE DAY ON WHICH YOU WERE UNABLE TO PERFORM YOUR REGULAR OR CUSTOMARY WORK. SECTION 2626, CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC).
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 2517-19 Rev. 3 (03-18) (INTRANET)