DI / DE 731DIS

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration for Issuance of Duplicate Disability Insurance (DI) Check

 
Date:
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Claim ID:
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CED:
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If you are reporting a lost, missing, or damaged check(s), please sign and date all copies of the enclosed Declaration for Issuance of Duplicate Disability Insurance (DI) Check, DE 731DIS. Return the Original and Duplicate to us in the envelope provided. This transmittal and the Client Copy of the Declaration are for your records.
If you have received the check or checks, disregard this letter and do not return the Declaration.
If you find the check or checks after returning the Declaration, DO NOT CASH THE CHECK! Immediately call our customer service center at 1-800-480-3287 for further instructions. Deaf, hard-of-hearing, or speech impaired persons may contact us via teletypewriter (TTY) at 1-800-563-2441.

Disability Insurance (DI) Program Representative

Enclosures:
DE 731DIS
 
Courtesy Reply Envelope

Instructions - You May Keep This Page For Your Records

DE 731DIS Rev. 18 (4-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration for Issuance of Duplicate Disability Insurance (DI) Check

 
Date:
Blank Line
Claim ID:
Blank Line
CED:
Blank Line
I,
Blank line 
,
residing at
Blank line 
,
Blank Line
,
declare that I received or should have received the following Disability Insurance (DI) check(s) issued by the Employment Development Department (EDD), State of California, to the order of 
Blank Line

Check Number

Issue Date

Number Benefit Days

Through Date

Amount
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line

and that the Disability Insurance (DI) check(s) has been either lost, stolen, or destroyed.

No part of the amounts of the check(s) listed above has been received by me, either directly or indirectly or applied to any use or purpose in my behalf. I agree to indemnify and hold harmless the State, its officers, and its employees from any loss resulting from the issuance of said duplicate warrant or check.

I, therefore, ask that a new check(s) be issued in lieu of the one(s) that has been either lost, stolen, or destroyed. In consideration of issuance, I HEREBY AGREE THAT IF I RECOVER THE ORIGINAL CHECK(S), I WILL NOT CASH IT BUT WILL IMMEDIATELY CONTACT STATE DISABILITY INSURANCE (SDI).

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Signed on
Blank lineMonth
Blank lineDay
Blank lineYear
at
Blank lineCity
Blank lineState
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CLAIMANT'S SIGNATURE
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DISABILITY INSURANCE (DI) REPRESENTATIVE

Return original and duplicate. Keep the transmittal/instructions and the client copy for your records.

SPACE BELOW IS TO BE USED BY INSURANCE ACCOUNTING DIVISION ONLY

REISSUANCE APPROVED:

Date:
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By:
Blank line 

DE 731DIS VOIDED:

 
Blank line
Name
Blank line
Date

Original

DE 731DIS Rev. 18 (4-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration for Issuance of Duplicate Disability Insurance (DI) Check

 
Date:
Blank Line
Claim ID:
Blank Line
CED:
Blank Line
I,
Blank line 
,
residing at
Blank line 
,
Blank Line
,
declare that I received or should have received the following Disability Insurance (DI) check(s) issued by the Employment Development Department (EDD), State of California, to the order of 
Blank Line

Check Number

Issue Date

Number Benefit Days

Through Date

Amount
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line

and that the Disability Insurance (DI) check(s) has been either lost, stolen, or destroyed.

No part of the amounts of the check(s) listed above has been received by me, either directly or indirectly or applied to any use or purpose in my behalf. I agree to indemnify and hold harmless the State, its officers, and its employees from any loss resulting from the issuance of said duplicate warrant or check.

I, therefore, ask that a new check(s) be issued in lieu of the one(s) that has been either lost, stolen, or destroyed. In consideration of issuance, I HEREBY AGREE THAT IF I RECOVER THE ORIGINAL CHECK(S), I WILL NOT CASH IT BUT WILL IMMEDIATELY CONTACT STATE DISABILITY INSURANCE (SDI).

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Signed on
Blank lineMonth
Blank lineDay
Blank lineYear
at
Blank lineCity
Blank lineState
Blank line
CLAIMANT'S SIGNATURE
Blank line
DISABILITY INSURANCE (DI) REPRESENTATIVE

Return original and duplicate. Keep the transmittal/instructions and the client copy for your records.

SPACE BELOW IS TO BE USED BY INSURANCE ACCOUNTING DIVISION ONLY

REISSUANCE APPROVED:

Date:
Blank line 
By:
Blank line 

DE 731DIS VOIDED:

 
Blank line
Name
Blank line
Date

Duplicate

DE 731DIS Rev. 18 (4-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration for Issuance of Duplicate Disability Insurance (DI) Check

 
Date:
Blank Line
Claim ID:
Blank Line
CED:
Blank Line
I,
Blank line 
,
residing at
Blank line 
,
Blank Line
,
declare that I received or should have received the following Disability Insurance (DI) check(s) issued by the Employment Development Department (EDD), State of California, to the order of 
Blank Line

Check Number

Issue Date

Number Benefit Days

Through Date

Amount
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line
Blank line
MM/DD/YY
Blank line
MM/DD/YY
Blank line

and that the Disability Insurance (DI) check(s) has been either lost, stolen, or destroyed.

No part of the amounts of the check(s) listed above has been received by me, either directly or indirectly or applied to any use or purpose in my behalf. I agree to indemnify and hold harmless the State, its officers, and its employees from any loss resulting from the issuance of said duplicate warrant or check.

I, therefore, ask that a new check(s) be issued in lieu of the one(s) that has been either lost, stolen, or destroyed. In consideration of issuance, I HEREBY AGREE THAT IF I RECOVER THE ORIGINAL CHECK(S), I WILL NOT CASH IT BUT WILL IMMEDIATELY CONTACT STATE DISABILITY INSURANCE (SDI).

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Signed on
Blank lineMonth
Blank lineDay
Blank lineYear
at
Blank lineCity
Blank lineState
Blank line
CLAIMANT'S SIGNATURE
Blank line
DISABILITY INSURANCE (DI) REPRESENTATIVE

Return original and duplicate. Keep the transmittal/instructions and the client copy for your records.

SPACE BELOW IS TO BE USED BY INSURANCE ACCOUNTING DIVISION ONLY

REISSUANCE APPROVED:

Date:
Blank line 
By:
Blank line 

DE 731DIS VOIDED:

 
Blank line
Name
Blank line
Date

Client Copy

DE 731DIS Rev. 18 (4-21) (INTRANET)