Disability Insurance - Request for State Disability Insurance Claim Form

Request for State Disability Insurance Claim Form
En Espa�ol

A Claim for State Disability Insurance Benefits, DE 2501, is available on-line, but you may have one mailed to you by completing and submitting the information below.

Name:	(Please enter your business name if you are an employer ordering more than 5 forms.)
Mailing Address:
City:
State:	Zip Code:
E-Mail Address:	if no E-Mail Address, please enter "none@edd.ca.gov"
Telephone Number:	please format: (999) 123-4567
	ENTER QUANTITY REQUESTED
DE 2501 - Claim for State Disability Insurance Benefits:
DE 2501/S - Spanish instructions for completing the DE 2501 claim form:
	NOTE: These are instructions in Spanish only; to file a claim, you must complete the DE 2501 (English).

NOTE: Submitting this information will send an unencrypted e-mail message to the SDI Customer Service Unit. This information will be used only to mail you a Claim for State Disability Insurance (SDI) Benefits, DE 2501, form.

If you prefer not to send this information over the Internet, please call your nearest State Disability Insurance Office.

For more information please call SDI at 1-800-480-3287 or 1-866-658-8846 (En Español)

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