DI / DE 2578N

SAMPLE, this page for reference only.

DISABILITY INSURANCE
PO BOX 00000
ANY CITY CA 99999-9999
FIRSTNAME M LASTNAME
‎1234 ANY ST
ANY CITY CA 99999-9999
 

NOTICE OF CONFLICTING LIABILITY

NAME
FIRSTNAME
MIDDLE NAME
LASTNAME
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY
YOU HAVE PROVIDED INFORMATION WHICH INDICATES THAT YOU MAY BE ENTITLED TO WORKERS' COMPENSATION BENEFITS. HOWEVER, SINCE YOUR ENTITLEMENT TO WORKERS' COMPENSATION CANNOT BE DETERMINED BY YOUR EMPLOYER OR THEIR INSURANCE COMPANY AT THIS TIME, THE EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD) WILL PAY YOUR CLAIM IF YOU ARE OTHERWISE ELIGIBLE. IF YOU SHOULD RECEIVE WORKERS' COMPENSATION AFTER EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD) HAS COMMENCED BENEFIT PAYMENTS, YOU MUST IMMEDIATELY CONTACT THE STATE DISABILITY INSURANCE (SDI) OFFICE HANDLING YOUR CLAIM.
EXISTING LAW PROVIDES THAT YOU ARE NOT ELIGIBLE FOR STATE DISABILITY INSURANCE (SDI) FOR ANY DAY THAT YOU RECEIVE OR ARE ENTITLED TO RECEIVE WORKERS' COMPENSATION BENEFITS EQUAL TO OR IN EXCESS OF YOUR SDI ENTITLEMENT. CONFLICTING WORKERS' COMPENSATION BENEFITS INCLUDE TEMPORARY DISABILITY (TD) PAYMENTS MADE TO YOU BY YOUR EMPLOYER OR THEIR INSURANCE CARRIER.

State of California / Employment Development Department (EDD)

DE 2578-N Rev. 3 (03-18) (INTRANET)