DI / DE 1000DCF

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For EDD's Use

Office of Appeals Case Number:
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DC:
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Voluntary Plan (VP) Number:
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Claim Date:
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Office Number:
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Appeal For Determination of Coverage

In the Matter of the Liability of:
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In the Matter of the Claim of:
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SSA Number
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Insurer-Respondent
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Employer
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Address
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Appellant determined the claimant eligible for Paid Family Leave (PFL) benefits and forwarded a copy of the claim to Respondent on
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Respondent denied coverage on
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Date
Respondent should accept coverage of this claim because
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Benefits Blank Line being paid to the claimant by the Appellant pending the decision of the Administrative Law Judge (ALJ).

Appellant's Name
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Appellant's Address
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Signature and Title of Authorized Representative
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Date

DE 1000DCF Rev. 1 (12-23) (INTRANET)