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De 2501 Form

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A DE 2501 Form is used by the Employment Development Department in the State of California. It is also known as a Claim for Disability Insurance Benefits - Claim Statement of Employee. Employees complete this form if they need to file a disability claim from an on the job injury so that they may receive insurance benefits through their employer. The employee will need to provide certain information including when they were hurt, when they were first unable to work, when they began receiving worker's compensation, the name of the adjustor, and the name of the employee's worker's compensation attorney if they've hired one.

De 2501
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What is a DE 2501 Form?

This form is used by the Employment Development Department of the State of California. It is known as a Claim for Disability Insurance Benefits – Claim Statement of Employee form. This form is used by someone who needs to file a disability claim so they can get insurance benefits through their employer.
This form requires a lot of personal information in order for the benefit claim to be processed. The person applying will also need to know information about their medical disability, such as the date it started, when it prevented you from working, and if it began due to a work injury.
If the disability is work related, extensive information surrounding worker’s compensation will be required. This will include dates you received worker’s comp, the adjuster for the benefits, and the name of the worker’s compensation attorney if you have hired one. 

How to complete a DE 2501 form (Step by Step)

To complete a DE 2501 Form you will need to provide the following information:

  • Health Insurance Portability and Accountability Act (HIPAA) Authorization
    • Social security number
    • Name
    • Person/organization providing the information
    • Signature
    • Date
  • Claimant’s Statement
    • Social security number
    • EDD customer account number
    • California driver license or ID number 
    • Gender
    • Other social security numbers used
    • State government employee bargaining unit #
    • Date of birth
    • Legal name
    • Any other names under which you have worked
    • Home phone number
    • Mobile phone number
    • Language preference
    • Mailing address
    • Residence address
    • Last or current employer, address, phone number
    • Whether you were in custody of law enforcement for a convicted violation during your disability
    • Last day you worked before your disability
    • Date disability began
    • Date you want to file claim
    • Whether you worked since your disability began
    • Date of recovery
    • Date of return to work
    • Regular occupation
    • Why you stopped working
    • Classification of job
    • Any pay you continue to receive during your disability
    • Authorization to disclose benefit amount to employers
    • Second employer information
    • Information about residence if an alcoholic recovery home or drug-free residential facility
    • Whether you have filed or intend to file for workers’ compensation benefits
    • Whether your disability was caused by your job
    • Dates of injury shown on workers’ compensation claim
    • Workers’ compensation insurance company information
    • Adjustor’s name
    • Employer’s name
    • Attorney’s name and contact information
    • Workers’ compensation appeals board/ADJ case number
    • Signature
    • Witness signature, contact information, date
    • Personal representative name, authorization, signature, date
  • Physician/Practitioner’s Certificate
    • Patient’s SSN
    • Patient’s file number
    • Electronic receipt number
    • Date of birth
    • Patient’s name
    • Physician’s license number
    • State or Country of license
    • License type
    • Specialty
    • Name as shown on license
    • Address
    • County hospital/government facility address
    • Patient treatment dates, intervals
    • Date of disability, cause and date
    • Date released or expected to release to work or permanent disability
    • Any pregnancy date
    • Any postpartum disability days
    • Any additional maternal disability conditions
    • ICD diagnosis codes for disability condition
    • Diagnosis
    • Findings
    • Type of treatment/medication rendered to patient
    • Hospitalization dates if applicable
    • Date of death if applicable
    • Whether patient was previously seen by another physician/practitioner for current disability
    • Date and type of surgery/procedure most recently performed
    • ICD procedure codes
    • Whether condition was caused or aggravated by patient’s regular or customary work
    • Whether you are completing form for the sole purpose of referral/recommendation to alcoholic recovery home or drug-free facility
    • Date patient became resident of drug or alcohol facility
    • Whether disclosure of information on form would be medically or psychologically detrimental to patient
    • Certification that patient is unable to perform regular or customary work because of the listed disabling conditions
      • Signature
      • Date
      • Phone number

How to file a disability insurance claim by mail

To file a disability insurance claim by mail, you will need to:

  1. Obtain a paper claim form (DE 2501)
    1. Visit Online Forms and Publications and order a form online
    2. Visit an SDI office
    3. Obtain the form from your physician or employer
    4. Call 1-800-480-3287
  2. Gather the required information
    1. Social security number
    2. California drivers license or identification card number
    3. Most recent employer’s information
    4. Dates of injury and last date worked
    5. Wages you received or expect to receive from your employer after you stopped working 
    6. Any worker’s compensation claim information
    7. Any information about your in-patient treatment at an alcoholic recovery home or drug-free facility
  3. Complete the Claimant’s statement
  4. Contact your physician/practitioner about completing the medical certification
  5. Mail the completed claim to:

    State of California
    Employment Development Department 
    P.O. Box 989777
    West Sacramento, CA 95798-9777

Download a PDF or Word Template

DE-2501

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433-A-OIC Form

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433-A Form

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433-B Form

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