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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 benefits 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.
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