Disability Insurance Form
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Please call us at 1 800 772 1213 tty 1 800 325 0778 monday through friday between 8 a m.
Disability insurance form. Submit your claim no earlier than nine days after the first day your disability begins but no later than 49 days after your disability begins. Do not fax the form. Mail the completed form to the edd in the envelope provided. Form ssa 16 06 2018 uf discontinue prior editions social security administration.
For those forms visit the online forms and publications section. The pdfs on this website are replicas of the official edd forms and publications. The disability benefits application process follows these general steps whether you apply online by phone or in person. Disability insurance di provides short term benefits to eligible workers who have a full or partial loss of wages due to a non work related illness injury or pregnancy.
You must apply for the coverage within one year from the date you receive notice of the grant of waiver of premiums. To complete forms you may need to download and save them on the computer then open them with the no cost adobe reader. Disability coverage that replaces at least 60 percent of your after tax income is generally recommended. Page 1 of 7 omb no.
To file a disability insurance di claim by mail complete and submit a claim for disability insurance di benefits de 2501. Visiting online forms and publications and ordering a form online to have it mailed to you. An example in spanish of a claim for disability insurance di benefits form for individuals claiming disability benefits. Application for disability insurance benefits.
I apply for a period of disability and or all insurance benefits for which i am eligible under title ii and part a of title xviii of the social security act as presently amended. The disability application process. Follow the steps below to properly submit a di claim by mail. State disability insurance forms and publications.
Visit online forms and publications to search view and order state disability insurance forms. To estimate the benefit amount you would need if you became disabled ask yourself how much monthly income would cover your living expenses. You gather the information and documents you need to apply. Or contact your local social security office.
Some forms and publications are translated by the department in other languages. Claim for disability insurance benefits religious practitioner s certificate de 2502 if you are under the care of an accredited religious practitioner you can download and print this form. It will help you gather the information you need to complete the application. De 2501 s spanish sample claim form spanish.
We recommend you print and review the adult disability checklist. Enter your social security number on all pages of the claim form including attachments. The form you are looking for is not available online. Obtain a paper claim form.
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