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Facts about the California Disability PDF template

This disability form is for residents of the state of California who are temporarily disabled, losing wages, and wish to file a claim for state disability insurance (SDI). If you are a worker in California and are found disabled by the State of California Employment Development Department, you might be eligible for SDI benefits.
Why is the California disability form PDF used?
The reason to use this form is to file a claim for California state disability insurance. If you are a California worker who is unable to work and losing wages due to a non-work-related injury, illness, pregnancy or childbirth, you may qualify for disability insurance.
Completing and filing a disability form with the state of California is your first step in the qualification process. Once the State of California Employment Development Department receives your completed form, it will open a case to determine your eligibility for SDI. If you are found eligible, then you will receive SDI benefits.

Who Would Use the California Disability Form PDF?

Any worker in California who cannot work due to an illness, injury, pregnancy, or childbirth would use this form to open a disability case. California SDI benefits are for workers who cannot work and are losing wages because of a non-work-related medical condition or injury. To qualify, you must have a California work history, been unable to work for eight days or more, and have lost wages as a result. Over 18 million California residents qualify for and receive SDI benefits.1

When Should You Use the California Disability Form PDF?

You should use this form if you have a non-work-related illness, injury, or other condition that prevents you from working in the state of California. For example, you should use the form if you have become pregnant or given birth recently. You should also use the form if you have been injured or diagnosed with an illness that is not related to or caused by your work.

What are the Consequences for not Using a California Disability Form PDF?

If you choose not to fill out a California state disability form, then you will not qualify for a disability insurance claim and will not be able to replace the wages you are losing. The only people who receive disability insurance claims are those who file a form and open a disability case. Without the form, the state of California will not open a disability case for you and you will not receive any SDI benefits.

Steps for Filling Out a California Disability Form PDF

The process of filling out a disability form in California is simple. Here is the information that you need to gather to complete a California disability form.

  1. Your name, social security number, and current address.
  2. The name and address of your employer.
  3. The date that you became disabled.
  4. Your type of occupation.
  5. The name, address, and telephone number of your attorney. (If you have one.)
  6. A completed physicians’ certificate.

Here are the step-by-step instructions you need to follow to complete the disability form:

  1. Fill in the boxes in the claimant’s statements area of the form. The boxes in the claimant’s statements area of the form include your name, address, social security number, employer’s name and address, type of occupation, and attorney’s information. The attorney’s information only applies if you have an attorney. It is not necessary for you to have an attorney to file for California SDI benefits.
  2. Review the form, sign and date it.
  3. Have your health care practitioner complete the physicians’ certificate.
  4. Mail or return the completed form in person to the State of California Employment Development Department.

Quick Questions

Individuals in California who are losing wages because they have a non-work-related illness, injury, or family circumstances that prevent them from working. To receive benefits, you need to:
1. File a claim.
2. Have a history of wages subject to SDI contributions during the past 12 months.
3. Obtain certification of your disability from your health care practitioner.

To qualify for disability insurance benefits in California, you will need your health care provider to complete a disability form on your behalf.

To complete your application, you will need your own and your employers’ name and address, your social security number, your occupation, and a completed disability form from your doctor. 1.

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