De 1857A Form – Fill Out and Use This PDF

UI

DI

PFL

THIS EMPLOYER IS REGISTERED UNDER THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE AND IS REPORTING WAGE CREDITS THAT ARE BEING ACCUMULATED FOR YOU TO BE USED AS A BASIS FOR:

Unemployment Insurance

(funded entirely by employers’ taxes)

When you are unemployed or working less than full time and are ready, willing, and able to work, you may be eligible to receive Unemployment Insurance (UI) benefits. There are three ways to file a claim:

Internet

File online with eApply4UI—the fast, easy way to file a UI claim! Access eApply4UI at https://eapply4ui.edd.ca.gov/.

Telephone

File by contacting a customer service representative at one of the toll-free numbers listed below:

English 1-800-300-5616	Spanish 1-800-326-8937
Cantonese 1-800-547-3506	Vietnamese 1-800-547-2058
Mandarin 1-866-303-0706	TTY (non voice) 1-800-815-9387

Mail or Fax

File by mailing or faxing UI Application, DE 1101I, by accessing the paper application online at www.edd.ca.gov/unemployment. The paper application can be filled out online and printed, or printed and completed by hand. Then the application can be mailed or faxed to an EDD office for processing.

Note: File promptly. If you delay in filing, you may lose benefits to which you would otherwise be entitled.

Disability Insurance

(funded entirely by employees’ contributions)

When you are unable to work or reduce your work hours because of sickness, injury, or pregnancy, you may be eligible to receive Disability Insurance (DI) benefits.

Your employer must provide a copy of Disability Insurance Provisions, DE 2515, to each newly hired employee and to each employee leaving work due to pregnancy or due to sickness or injury that is not job related.

To file a claim:

Online, create an account at www.edd.ca.gov/disability. This is the easiest and fastest way to file a new claim and obtain claim status information.

By mail, obtain the data capturing Claim for Disability Insurance Benefits (Optical Character Recognition), DE 2501, from your employer, physician/practitioner, hospital, by calling us at 1-800-480-3287, or online at www.edd.ca.gov/forms.

Note: If your employer maintains an approved Voluntary Plan for DI coverage, contact your employer for assistance.

FOR MORE INFORMATION ABOUT DI, PLEASE VISIT www.edd.ca.gov/disability OR

CONTACT DI CUSTOMER SERVICE BY PHONE AT 1-800-480-3287.

STATE GOVERNMENT EMPLOYEES SHOULD CALL 1-866-352-7675.

TTY (FOR DEAF OR HEARING-IMPAIRED INDIVIDUALS ONLY) IS AVAILABLE AT 1-800-563-2441.

Paid Family Leave

(funded entirely by employees’ contributions)

When you stop working or reduce your work hours to care for a family member who is seriously ill or to bond with a new child, you may be eligible to receive Paid Family Leave (PFL) benefits.

Your employer must provide a copy of Paid Family Leave Program Brochure, DE 2511, to each newly hired employee and to each employee leaving work to care for a seriously ill family member or to bond with a new child.

To file a claim:

Online, create an account at www.edd.ca.gov/disability. This is the easiest and fastest way to file a new claim.

By mail, obtain the data capturing Claim for Paid Family Leave Benefits (Optical Character Recognition),

DE 2501F, from your employer, physician/practitioner, hospital, by calling us at 1-877-238-4373, or online at www.edd.ca.gov/forms.

Note: If your employer maintains an approved Voluntary Plan for PFL coverage, contact your employer for assistance.

FOR MORE INFORMATION ABOUT PFL, PLEASE VISIT www.edd.ca.gov/disability OR

CONTACT CUSTOMER SERVICE BY PHONE AT 1-877-238-4373.

STATE GOVERNMENT EMPLOYEES SHOULD CALL 1-877-945-4747.

TTY (FOR DEAF OR HEARING-IMPAIRED INDIVIDUALS ONLY) IS AVAILABLE AT 1-800-445-1312.

NOTE: SOME EMPLOYEES MAY BE EXEMPT FROM COVERAGE BY THE ABOVE INSURANCE PROGRAMS. IT IS ILLEGAL TO MAKE A FALSE STATEMENT OR TO WITHHOLD FACTS TO CLAIM BENEFITS. FOR ADDITIONAL GENERAL INFORMATION, VISIT THE EDD WEBSITE AT www.edd.ca.gov.