Paid Family Leave Insurance - Request A Claim Form for Paid Family Leave Benefits

Name:
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

If you are a woman currently receiving SDI pregnancy-related benefits, it is not necessary to request a Claim for Paid Family Leave Benefits. You will automatically be sent a Claim for Paid Family Leave (PFL) Benefits - New Mother, DE 2501FP, when your pregnancy-related disability claim ends.

Submitting this information will send an unencrypted e-mail message to the Paid Family Leave Customer Service Unit. This information will be used only to mail you a Claim for Paid Family Leave Benefits, DE 2501F. Please allow 5-7 working days to receive your order. If you prefer not to request a claim form over the Internet, please call one of the following toll-free numbers: