DI / DE 8517-18

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 DETERMINATION

 
Mailing Date:
MM/DD/YY
Claim Effective Date:
MM/DD/YY

Your claim for Non-Industrial Disability Insurance (NDI) has been disallowed from MM/DD/YY through MM/DD/YY because:

After reducing the amount of temporary disability indemnity which you have received from the maximum amount of NDI payable, you have exhausted the maximum benefits payable for your present benefit period.

REASON FOR DETERMINATION:

Section 19879(a) , 19882(c) California Government 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 8517-18 (03/18) (INTRANET)