DI / DE 2578FF

SAMPLE, this page for reference only.

EDD-PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
RETURN TO
EDD- PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
 
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WORKERS’ COMPENSATION INFORMATION REQUEST- PAID FAMILY LEAVE (PFL)

For Office Use Only
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NAME
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Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY

Your claim for Paid Family Leave (PFL) benefits indicates that you may be claiming Workers’ Compensation (WC) benefits during your PFL claim period. In most cases, you are not eligible to receive PFL for the same day(s) you receive or are eligible to receive WC (temporary disability (TD), permanent disability (PD), vocational rehabilitation, or maintenance allowance) benefits through your employer or your employer’s insurance company.

To avoid any delay in processing your claim, you may contact us by phone with responses to the following questions. Otherwise, complete and mail this form to us as soon as possible.

  1. Are you claiming WC benefits for any day(s) during the same period that you are claiming PFL benefits?
  2. If you answered “Yes” to question #1, what is the date of your work-related injury or disability?
    Blank line
  3. Have you notified your employer about your work related injury/disability?
    If Yes, has your employer accepted liability for your claim?
    Your Claim Number Blank line
  4. WC Insurance Carrier Information:
    Claim Adjuster’s Name Blank line
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    Insurer's Name
    Blank Line
    Phone
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    Insurer's Address
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    City
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    State
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    ZIP Code
  5. Have you or will you receive WC (temporary disability (TD), permanent disability (PD), vocational rehabilitation, and/or maintenance allowance) benefits?
    If Yes, for what period and weekly amount? From Blank line to Blank line at $ Blank line per week.
    Type of benefits you received or will receive:Blank line

DE 2578FF Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only.

 
Mailing Date:
MM/DD/YY
  1. Have you filed an application/claim with the Workers' Compensation Appeals Board (WCAB)?
    1. If yes, what is the assigned WCAB case number(s)? Blank line Blank line Blank line
  2. Is there a WCAB case settlement?
    Type of case settlementBlank line
  3. If you have an attorney representing you, please provide the following:
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    Attorney's Name
    Blank line
     Phone 
    Blank Line
    Address
    Blank Line
    City
    Blank Line
    State
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    ZIP Code
I certify that the above statements are true to the best of my knowledge. I understand that I may not be eligible to receive PFL and WC benefits for the same period and will immediately notify the Employment Development Department (EDD) if I receive workers' compensation benefits through my employer or my employer's insurance company.
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Your Signature
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 Date 

DE 2578FF Rev. 2 (11-21) (INTRANET)