The DE 2501 form, Application for Disability Insurance Benefits, is the claim the California Employment Development Department (EDD) uses to pay Disability Insurance benefits when a disability keeps you from doing your regular work. It has two parts: Part A, the Claimant's Statement, and Part B, the Physician/Practitioner's Certificate. EDD must receive both for the application to be complete. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; EDD publishes the form at edd.ca.gov and also accepts claims through SDI Online.
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What is DE 2501?
Form DE 2501, Application for Disability Insurance Benefits, is the California Employment Development Department (EDD) application for Disability Insurance (DI) benefits, which provide up to 52 weeks of benefit payments to people who cannot do their regular work because of a disability.
EDD defines a disability as an illness or injury, physical or mental; surgery, including elective surgery; or pregnancy and childbirth. The application has two parts. Part A is the Claimant's Statement, which you complete and sign. Part B is the Physician/Practitioner's Certificate, which your licensed health professional completes and signs, either on paper or through SDI Online.
Once EDD receives a complete application, it mails a Notice of Computation (DE 429D) showing what your weekly payments could be. On the form you choose your payment method in question A39: debit card or check. EDD states that direct deposit is available only if you apply through SDI Online.
Neighboring EDD documents serve other cases. The Claim for Disability Insurance Benefits - Religious Practitioner's Certificate (DE 2502) replaces Part B when an accredited religious practitioner treats you. The Claim for Nonindustrial Disability Insurance (NDI) (DE 8501) is for state government employees in certain bargaining units. The Application for Paid Family Leave Benefits (DE 2501F) is the separate Paid Family Leave application.
Who needs to file DE 2501?
Workers in California who cannot do their regular work because of a disability, and who meet EDD's basic eligibility rules, use this application. EDD says to apply even if you are not sure you are eligible; it will tell you if you are ineligible for all or part of the claim.
The form lists these basic requirements:
- You are unable to do your regular work for at least eight consecutive days.
- You were employed or actively looking for work when the disability began, and you lost wages because of it.
- You earned enough wages with State Disability Insurance (SDI) deductions during your base period.
- You are under the care of a licensed health professional during the first eight days of the disability and stay under care to keep receiving benefits.
Do not complete this application if you are insured by a Voluntary Plan (ask your employer how to apply) or if you are a state government employee in bargaining unit 2, 5, 6, 7, 8, 9, 10, 12, 13, 16, 18 or 19. Those employees use the DE 8501.
You may be ineligible if you are claiming or receiving unemployment or Paid Family Leave benefits, are in jail or prison after a conviction, or receive Workers' Compensation at a weekly rate equal to or greater than the disability rate.
If you cannot complete the application because of your disability, or you are an authorized representative for an incapacitated or deceased person, call 1-800-480-3287 or use Ask EDD at askedd.edd.ca.gov.
When to file DE 2501
You can apply nine days after you become unable to do your regular work because of your disability, and you must apply within 49 days of the date the disability began or you may lose benefits. If the application is late, include a written explanation of why. For question A18, the first day you could not do your regular work is the date your disability began.
For a pregnancy claim, EDD says not to submit the application until after the eighth day following the date your licensed health professional certifies your disability. If you want your claim to start later so that you have a different base period, call 1-800-480-3287 before you submit; you cannot change the start date after a valid claim is established.
If you return to work but are again unable to do your regular work, submit a new application right away and report the dates you worked.
After EDD receives both Part A and Part B, you should get information by mail in about two weeks. Most claims are processed and payments issued within 14 days of receiving both parts. The first seven days of a claim are an unpaid waiting period.
Documents you need
- Part B, the Physician/Practitioner's Certificate, completed and signed by your licensed health professional; EDD must receive Part A and Part B for the application to be complete.
- Claim for Disability Insurance Benefits - Religious Practitioner's Certificate (DE 2502), only if you are under the care of an accredited religious practitioner; the practitioner completes and signs it.
- A written explanation of why the application is late, only if you submit it more than 49 days after your disability began.
- The Workers' Compensation status letter from the insurance carrier, only if you have a work-related disability and the claim has been accepted, denied or delayed.
- A copy of the power of attorney, or the Declaration of Individual Claiming Disability Insurance Benefits Due an Incapacitated or Deceased Claimant (DE 2522), only if a personal representative signs for the claimant (question A42).
- Two witnesses' signatures and addresses, only if your signature is made by mark (x) (question A41); private mailbox addresses are not acceptable for witnesses.
How to fill out DE 2501
Complete the HIPAA authorization
On the Health Insurance Portability and Accountability Act (HIPAA) Authorization page, enter your Social Security number and name, and the person or organization providing your health information. Sign and date it; the form says refusing to sign may leave the claim incomplete.
Enter identity details in A1 to A5
A1: your Social Security number. A2: your EDD customer account number or ID, if you have one. A3: California driver license or ID number. A4: gender. A5: any other Social Security numbers you have used.
Answer state employment, birth date and names
A6: check Yes or No for state government employee, with your bargaining unit number if yes. A7: date of birth. A8: full legal name. A9: any other names you worked under, such as a maiden name.
Enter phone, language and addresses
A10 and A11: home and cell phone numbers with area code. A12: preferred language. A13: mailing address, starting with "PMB" for a private mailbox. A14: the address where you live, required only if it differs from A13.
Describe your last or current employer
A15: employer name, address and phone; enter "self" if you were self-employed. A16: whether you were in custody of law enforcement because of a conviction. A17: the last day you worked before your disability began.
Enter disability and work dates
A18: the date your disability began, which is the first day you could not do your regular work. A19: a later claim start date, only if you want one. A20: whether you have worked since; A21 A: recovery date; A21 B: date you returned to work.
Describe your occupation and job
A22: Social Security number again. A23: your regular or customary occupation. A24: select one reason you stopped working. A25: select the description that matches your job's physical demands.
Report employer pay and other employers
A26: type of pay your employer continued, if any. A27: whether EDD may disclose payment information to your employers. A28 to A29: second employer details and the box for more than two employers. A30: facility details only if you live in a recovery home or drug-free facility.
Complete workers' compensation items
A31: whether you have filed or will file for workers' compensation. If Yes, complete A32 through A38 (injury dates, insurer, adjuster, employer, attorney); if No, skip A33 to A38. Include the carrier's status letter if the claim was accepted, denied or delayed.
Select your payment method
A39: choose Debit Card or Check. EDD states that direct deposit requires applying through SDI Online.
Sign the declaration
A40: sign and date the declaration; do not print your name in the signature box. A41: check the box if you sign by mark (x) and add two witnesses with addresses. A42: a personal representative checks the box, completes the section and attaches the power of attorney or DE 2522.
Pass Part B to your health professional
Your licensed health professional completes B1 to B33, including the diagnosis (B19, B20), the return-to-work date (B14) and an original signature in B33. If they use SDI Online instead, they do not need the paper Part B.
Review and download the completed PDF
Check each answer, the Social Security number on every page and your signature. Download or print the completed PDF from FillingPDF, then follow the channels described under How to submit.
How to submit DE 2501
You can submit the application by mail or through SDI Online. The form prints no street address for mailing claims.
- By mail: Mail the completed application, Part A and Part B together, in the envelope EDD provides. EDD warns that a late application, or one with errors or missing information, can delay your claim or lead to denial. The EDD agency page says you must use an original paper application form and cannot print or download a copy of the English claim form. You can get one by ordering it online, from your physician/practitioner or employer, at an SDI Office, or by calling 1-800-480-3287 and saying "Claim form". Allow up to ten days for delivery.
- SDI Online: Apply at edd.ca.gov/SDI_Online through your myEDD account. EDD recommends this for faster processing, and direct deposit requires it. Your health professional can also submit Part B there.
- Part B: If your health professional uses the paper Part B, make sure it is submitted with Part A.
For help or accommodations, call 1-800-480-3287 or 1 (866) 490-8879 (voice); TTY users call the California Relay Service at 711. FillingPDF lets you fill out and download the PDF; submission follows the EDD channels above.
Common mistakes to avoid
- Filing more than 49 days after the disability began without a written explanation of why the application is late; EDD says you may lose benefits.
- Sending Part A without Part B. The application is complete only when EDD receives both parts.
- Using a rubber stamp for a signature. EDD does not accept rubber stamped signatures, and Part B asks for the practitioner's original signature.
- Completing the form in ink other than black, or writing outside the boxes provided.
- Leaving the Social Security number off pages of the application or attachments; EDD asks for it on all pages, unless you have none.
- Entering a private mailbox in question A13 without "PMB" at the beginning of the address.
- Entering "unknown" or "indefinite" as the return-to-work date in B14; the form says these are not acceptable.
- Leaving out the ICD diagnosis code(s) in B19 or the diagnosis in B20, both marked required.
- Using DE 2501 as a state government employee in one of the listed bargaining units, or when insured by a Voluntary Plan.
Frequently asked questions
What is the DE 2501 form?
The DE 2501 form is the California EDD's Application for Disability Insurance Benefits. You use it to claim up to 52 weeks of benefit payments when an illness, injury, surgery, pregnancy or childbirth keeps you from doing your regular work. It has Part A for you and Part B for your health professional.
What is the deadline for submitting the DE 2501?
Apply within 49 days of the date your disability began, or you may lose benefits. You can apply nine days after you are unable to do your regular work. If you are late, include a written explanation of why your application is late.
Who should not use the DE 2501 form?
Do not use it if you are insured by a Voluntary Plan; ask your employer how to apply. State government employees in bargaining unit 2, 5, 6, 7, 8, 9, 10, 12, 13, 16, 18 or 19 use the Claim for Nonindustrial Disability Insurance (NDI) (DE 8501) instead.
Who completes Part B of the DE 2501?
Your licensed health professional completes and signs Part B, either on paper or through SDI Online. A licensed midwife or nurse-midwife can certify normal pregnancy or childbirth. If you see an accredited religious practitioner, they complete the DE 2502 instead.
How long does it take to get paid after submitting?
EDD says you should receive information by mail about two weeks after it gets both Part A and Part B. Most claims are processed and paid within 14 days of receiving both parts, though processing time can vary. The first seven days are an unpaid waiting period.
Can I fill out the DE 2501 online and mail it?
You can fill out the PDF online on FillingPDF and download or print it, but FillingPDF does not file anything with EDD. EDD's page says you must use an original paper application and cannot print or download a copy of the English form, so confirm with EDD at 1-800-480-3287 or apply through SDI Online.
Can someone apply for me if I am too sick or have died?
Yes, in limited cases. An authorized representative signs in question A42 and attaches a copy of the power of attorney or the Declaration of Individual Claiming Disability Insurance Benefits Due an Incapacitated or Deceased Claimant (DE 2522). Call 1-800-480-3287 for help.
How do I receive DE 2501 benefit payments?
Choose Debit Card or Check in question A39. Checks take 7 to 10 days to arrive by mail. EDD says direct deposit is the fastest and most secure option, but you must apply through SDI Online to receive it.
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