&ODLP IRU 'LVDELOLW\ ,QVXUDQFH %HQHILWV ² &ODLP 6WDWHPHQW RI (PSOR\HH TYPE or PRINT with BLACK INK. 1A. YOUR SOCIAL SECURITY NUMBER 1B. IF YOU HAVE EVER USED OTHER SOCIAL SECURITY NUMBERS, SHOW THOSE NUMBERS BELOW 2. STATE GOVERNMENT EMPLOYEE (IF YES, INDICATE BARGAINING UNIT #.) YES 4. LAST DATE YOU WORKED 3. DATE YOUR DISABILITY BEGAN 5. HAVE YOU WORKED ANY FULL OR PARTIAL DAYS SINCE YOUR DISABILITY BEGAN? YES MM DD 7. GENDER MALE YY MM DD FIRST NAME NO NO MM YY 8. YOUR LEGAL NAME FEMALE (UNIT #) 6. DATE YOU RECOVERED OR RETURNED TO WORK (IF ANY) DD YY 9. YOUR DATE OF BIRTH MIDDLE NAME OR INITIAL LAST NAME 10. OTHER NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED MM DD YY 11. LANGUAGE YOU PREFER TO USE ________________________ ENGLISH ESPAÑOL OTHER 12. YOUR MAILING ADDRESS (IF YOU WISH TO RECEIVE MAIL AT A PRIVATE MAIL BOX—NOT A US POSTAL SERVICE BOX—YOU MUST SHOW THE NUMBER IN THE “PMB#” SPACE.) NUMBER / STREET / P.O. BOX / APARTMENT OR SPACE # PMB CITY STATE 13. YOUR AREA CODE AND TELEPHONE NUMBER # (PRIVATE MAIL BOX #) COUNTRY (IF NOT UNITED STATES OF AMERICA) ZIP CODE 14. YOUR RESIDENCE ADDRESS, IF DIFFERENT FROM YOUR MAILING ADDRESS NUMBER / STREET / APARTMENT OR SPACE # ( ) CITY STATE COUNTRY (IF NOT UNITED STATES OF AMERICA) ZIP CODE 15. WHY DID YOU STOP WORKING? 16. YOUR LAST OR CURRENT EMPLOYER – IF YOUR LAST OR CURRENT EMPLOYMENT WAS SELF-EMPLOYMENT, ENTER “SELF” EMPLOYER ‘S AREA CODE AND TELEPHONE NUMBER ( NAME OF EMPLOYER [STATE GOVERNMENT EMPLOYEES: PROVIDE THE AGENCY OR DEPARTMENT NAME (FOR EXAMPLE: CALTRANS)] ) NUMBER / STREET / SUITE # (STATE GOVERNMENT EMPLOYEES: PLEASE PROVIDE THE ADDRESS OF YOUR PERSONNEL OFFICE) CITY STATE 17. YOUR REGULAR OCCUPATION COUNTRY (IF NOT UNITED STATES OF AMERICA) 18. IF YOUR EMPLOYER CONTINUED TO PAY YOU, INDICATE TYPE OF PAY ZIP CODE 19. MAY WE DISCLOSE BENEFIT PAYMENT INFORMATION TO YOUR EMPLOYER? ________________ SICK VACATION OTHER YES NO 20. SECOND EMPLOYER (IF YOU HAVE MORE THAN ONE EMPLOYER) EMPLOYER ‘S AREA CODE AND TELEPHONE NUMBER ( NAME OF EMPLOYER ) NUMBER / STREET / SUITE # CITY STATE COUNTRY (IF NOT UNITED STATES OF AMERICA) ZIP CODE 21. AT ANY TIME DURING YOUR DISABILITY WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT AUTHORITIES BECAUSE YOU WERE CONVICTED OF VIOLATING A LAW OR ORDINANCE? IF “YES,” INDICATE NAME OF FACILITY: YES ____________________________________________________________________________________ NO DE 2501 Rev. 77 (3-06) (INTERNET) Page 1 of 4 CU American LegalNet, Inc. www.USCourtForms.com Claim Statement of Employee - continued 22. PLEASE RE-ENTER YOUR SOCIAL SECURITY NUMBER............................................................................................................................... 23. IF YOU ARE A RESIDENT OF AN ALCOHOLIC RECOVERY HOME OR A DRUG-FREE RESIDENTIAL FACILITY, SHOW THE NAME, TELEPHONE NUMBER, AND ADDRESS NAME OF FACILITY FACILITY AREA CODE AND TELEPHONE NUMBER ( ) ADDRESS OF FACILITY (NUMBER AND STREET / CITY / STATE / ZIP CODE) 24. HAVE YOU FILED OR DO YOU INTEND TO FILE FOR WORKERS’ COMPENSATION BENEFITS? à 25. WAS THIS DISABILITY CAUSED BY YOUR JOB? YES–COMPLETE ITEMS 25 THROUGH 32 NO– COMPLETE ITEMS 25, 31 AND 32 à 26. DATE(S) OF INJURY SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM YES NO 27. WORKERS’ COMPENSATION INSURANCE COMPANY COMPANY NAME COMPANY AREA CODE AND TELEPHONE NUMBER ( ) NUMBER / STREET / SUITE # CITY STATE ZIP CODE YOUR WORKERS’ COMPENSATION CLAIM NUMBER 28. WORKERS’ COMPENSATION ADJUSTER ADJUSTER NAME ADJUSTER AREA CODE AND TELEPHONE NUMBER ( ) 29. EMPLOYER SHOWN ON YOUR WORKERS’ COMPENSATION CLAIM EMPLOYER NAME EMPLOYER AREA CODE AND TELEPHONE NUMBER ( ) 30. YOUR ATTORNEY (IF ANY) FOR YOUR WORKERS’ COMPENSATION CASE ATTORNEY NAME ATTORNEY AREA CODE AND TELEPHONE NUMBER ( ) NUMBER / STREET / SUITE # CITY STATE ZIP CODE WORKERS’ COMPENSATION APPEALS BOARD CASE NUMBER 3/($6( 5(9,(: 6,*1 $1' '$7( %27+ 12  $1' 12  31. Health Insurance Portability and Accountability Act Authorization. I authorize any physician, practitioner, hospital, vocational rehabilitation counselor, or workers’ compensation insurance carrier to furnish and disclose to employees of California Employment Development Department (EDD) all facts concerning my disability that are within their knowledge and to allow inspection of and provide copies of any medical, vocational rehabilitation, and billing records concerning my disability that are under their control. I understand that EDD may disclose information as authorized by the California Unemployment Insurance Code and that such redisclosed information may no longer be protected by this rule. I agree that photocopies of this authorization shall be as valid as the original. I understand that, unless revoked by me in writing, this authorization is valid for fifteen years from the date received by EDD or the effective date of the claim, whichever is later. I understand that I may not revoke this authorization to avoid prosecution or to prevent EDD’s recovery of monies to which it is legally entitled. Claimant’s Signature (DO NOT PRINT) Date Signed 32. Declaration and Signature. By my signature on this claim statement, I claim benefits and certify that for the period covered by this claim I was unemployed and disabled. I understand that willfully making a false statement or concealing a material fact in order to obtain payment of benefits is a violation of California law and that such violation is punishable by imprisonment or fine or both. I declare under penalty of perjury that the foregoing statement, including any accompanying statements, is to the best of my knowledge and belief true, correct, and complete. By my signature on this claim statement, I authorize the California Department of Industrial Relations and my employer to furnish and disclose to State Disability Insurance all facts concerning my disability, wages or earnings, and benefit payments that are within their knowledge. By my signature on this claim statement, I authorize release and use of information as stated in the “Information Collection and Access” portion of this form. I agree that photocopies of this authorization shall be as valid as the original, and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of the claim, whichever is later. Claimant’s Signature (DO NOT PRINT) Date Signed If your signature is made by mark (X), it must be attested by two witnesses with their addresses 1st Witness Signature and Address 2nd Witness Signature and Address 33. Personal Representative signing on behalf of claimant must complete the following: I,______________________________________ , represent the claimant in this matter as authorized by power of attorney (attach copy) Declaration of Individual Claiming Disability Insurance Benefits Due an Incapacitated or Deceased Claimant, DE 2522 (see pg. A,#4) Personal Representative’s Signature (DO NOT PRINT) Date Signed DE 2501 Rev. 77 (3-06) (INTERNET) Page 2 of 4 CU American LegalNet, Inc. www.USCourtForms.com ÃÃ8yhv€Ãs‚…Ã9v†hivyv‡’ÃD†ˆ…hprÃ7rrsv‡†Ã²Ã9‚p‡‚…·†Ã8r…‡vsvph‡r TYPE or PRINT with BLACK INK. 34. PATIENT’S FILE NUMBER 35. PATIENT’S SOCIAL SECURITY NO. 36. PATIENT’S LAST NAME 37. DOCTOR’S NAME AS SHOWN ON LICENSE 38. DOCTOR’S TELEPHONE NUMBER ( 39. DOCTOR’S STATE LICENSE NO. ) 40. DOCTOR’S ADDRESS – NUMBER AND STREET, CITY, STATE, COUNTRY (IF NOT USA), ZIP CODE. POST OFFICE BOX NUMBER IS NOT ACCEPTED AS THE SOLE ADDRESS 41. THIS PATIENT HAS BEEN UNDER MY CARE AND TREATMENT FOR THIS MEDICAL PROBLEM FROM _______/_______/________ TO _______/_______/________ AT INTERVALS OF DAILY WEEKLY 42. AT ANY TIME DURING YOUR ATTENDANCE FOR THIS MEDICAL PROBLEM, HAS THE PATIENT BEEN INCAPABLE OF PERFORMING HIS/HER REGULAR OR CUSTOMARY WORK? NO – SKIP TO THE DOCTOR’S YES – ENTER DATE DISABILITY BEGAN: CERTIFICATION SECTION _______/_______/_______ MONTHLY AS NEEDED 43. DATE YOU RELEASED OR ANTICIPATE RELEASING PATIENT TO RETURN TO HIS/HER REGULAR / CUSTOMARY WORK (“UNKNOWN,” “INDEFINITE,” ETC., NOT ACCEPTED.) ________/_______/_________ 45. ICD9 DISEASE CODE(S), SECONDARY 44. ICD9 DISEASE CODE, PRIMARY (REQUIRED UNLESS DIAGNOSIS NOT YET OBTAINED) _________ . _____ _________ . _____, _________ . _____, _________ . _____ 46. DIAGNOSIS (REQUIRED) – IF NO DIAGNOSIS HAS BEEN DETERMINED, ENTER OBJECTIVE FINDINGS OR A DETAILED STATEMENT OF SYMPTOMS 47. FINDINGS – STATE NATURE, SEVERITY, AND EXTENT OF THE INCAPACITATING DISEASE OR INJURY. INCLUDE ANY OTHER DISABLING CONDITIONS 48. TYPE OF TREATMENT / MEDICATION RENDERED TO PATIENT 49. IF PATIENT WAS HOSPITALIZED, PROVIDE DATES OF ENTRY AND DISCHARGE ______/_____/_______ TO ______/_____/_______ 50. DATE AND TYPE OF SURGERY / PROCEDURE PERFORMED OR TO BE PERFORMED ICD9 PROCEDURE CODE(S) ______/_____/_______ 51. IF PATIENT IS NOW PREGNANT OR HAS BEEN PREGNANT, WHAT DATE DID PREGNANCY TERMINATE OR WHAT DATE DO YOU EXPECT DELIVERY? 52. IF PREGNANCY IS / WAS ABNORMAL, STATE THE ABNORMAL AND INVOLUNTARY COMPLICATION CAUSING MATERNAL DISABILITY ______/______/_______ 53. BASED ON YOUR EXAMINATION OF PATIENT, IS THIS DISABILITY THE RESULT OF “OCCUPATION,” EITHER AS AN “INDUSTRIAL ACCIDENT” OR AS AN “OCCUPATIONAL DISEASE”? (INCLUDE SITUATIONS WHERE PATIENT’S OCCUPATION HAS AGGRAVATED PRE-EXISTING CONDITIONS.) YES NO 54. ARE YOU COMPLETING THIS FORM FOR THE SOLE PURPOSE OF REFERRAL / RECOMMENDATION TO AN ALCOHOLIC RECOVERY HOME OR DRUG-FREE RESIDENTIAL FACILITY AS INDICATED BY THE PATIENT IN QUESTION 23? YES 55. WOULD DISCLOSURE OF THIS INFORMATION TO YOUR PATIENT BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL? NO YES NO Doctor’s Certification and Signature (REQUIRED): Having considered the patient’s regular or customary work, I certify under penalty of perjury that, based on my examination, this Doctor’s Certificate truly describes the patient’s disability (if any) and the estimated duration thereof. I further certify that I am a licensed to practice in the State of (TYPE OF DOCTOR) . (SPECIALTY, IF ANY) ORIGINAL SIGNATURE OF ATTENDING DOCTOR – RUBBER STAMP IS NOT ACCEPTABLE DATE SIGNED Under sections 2116 and 2122 of the California Unemployment Insurance Code, it is a violation for any individual who, with intent to defraud, falsely certifies the medical condition of any person in order to obtain disability insurance benefits, whether for the maker or for any other person, and is punishable by imprisonment and/or a fine not exceeding $20,000. Section 1143 requires additional administrative penalties. DE 2501 Rev. 77 (3-06) (INTERNET) Page 3 of 4 CU American LegalNet, Inc. www.USCourtForms.com Health Insurance Portability and Accountability Act (HIPAA) Authorization State Disability Insurance Claimant: 1. Complete, sign, and date this form. 2. Take the completed signed form to your doctor. CLAIMANT’S NAME (FIRST, MIDDLE INITIAL, LAST) CLAIMANT’S SOCIAL SECURITY NUMBER I authorize any physician, practitioner, hospital, vocational rehabilitation counselor, or workers’ compensation insurance carrier to furnish and disclose to employees of California Employment Development Department (EDD) all facts concerning my disability that are within their knowledge and to allow inspection of and provide copies of any medical, vocational rehabilitation, and billing records concerning my disability that are under their control. I understand that EDD may disclose information as authorized by the California Unemployment Insurance Code and that such redisclosed information may no longer be protected by this rule. I agree that photocopies of this authorization shall be as valid as the original. I understand that, unless revoked by me in writing, this authorization is valid for fifteen years from the date received by EDD or the effective date of the claim, whichever is later. I understand that I may not revoke this authorization to avoid prosecution or to prevent EDD’s recovery of monies to which it is legally entitled. CLAIMANT’S SIGNATURE DE 2501 Rev. 77 (3-06) (INTERNET) (DO NOT PRINT) Page 4 of 4 DATE SIGNED CU American LegalNet, Inc. www.USCourtForms.com