Form De 2523 PDF Details

Understanding the intricacies of disability benefits can often seem daunting, yet it's crucial for both employers and employees navigating through periods of disability. At the heart of managing these benefits, especially within voluntary plans, is the DE 2523 form. This document plays a key role in reporting disability claims, ensuring that individuals receive the support they require during challenging times. Claimants are asked to provide comprehensive information ranging from personal identification to the specifics of their disability, including the diagnosis or International Classification of Diseases (ICD) Code. The form mandates the submission of initial claim details promptly within 15 days after a first claim for disability benefits is made. Additionally, it calls for updates, including the total amount of benefits disbursed and any amounts diverted for support obligations, to be submitted within 35 days after the final payment. This process not only streamlines the management of disability benefits but also ensures transparency and compliance with the relevant regulations. The form serves as a critical communication tool between the claimant, the employer, or the plan administrator and the Department, facilitating a smoother transition for employees during their period of disability, and keeping all parties informed of the claim's progress and status.

QuestionAnswer
Form NameForm De 2523
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesde2523 de2523 form

Form Preview Example

REPORT OF VOLUNTARY PLAN DISABILITY CLAIM

PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM. TO REPORT A VOLUNTARY PLAN FAMILY LEAVE (VPFL) CLAIM, YOU MUST SUBMIT A COMPLETED REPORT OF VOLUNTARY PLAN FAMILY LEAVE CLAIM, DE 2523F.

CLAIMANT INFORMATION

COMPLETE ITEMS 1 – 10 AND 16 – 18. SUBMIT WITHIN 15 DAYS AFTER RECEIPT OF A FIRST CLAIM FOR DISABILITY BENEFITS.

1.

SOCIAL SECURITY NUMBER

2. CLAIMANT’S NAME (FIRST, MIDDLE, LAST)

 

 

3.

DATE DISABILITY BEGAN

 

 

 

–

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

CLAIMANT’S MAILING ADDRESS

 

 

 

 

5.

SEX

 

 

 

 

 

 

STREET/PO BOX

 

 

 

 

 

 

 

MALE

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

STATE

ZIP CODE

 

6.

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

VOLUNTARY PLAN NUMBER

8. VOLUNTARY PLAN EMPLOYER NAME

 

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.DIAGNOSIS OR INTERNATIONAL CLASSIFICATION OF DISEASES (ICD) CODE

10.DO YOU WANT STATE AWARD INFORMATION?

NO

YES (REMINDER: IF YES, YOU MUST COMPLETE THE ADDRESS AREA AT THE BOTTOM OF THIS PAGE.)

FOR DEPARTMENT USE ONLY

CLAIM EFFECTIVE DATE

WEEKLY BENEFIT AMOUNT

$

MAXIMUM BENEFIT AMOUNT

$

COMPLETE ITEMS 11 – 18 AND SUBMIT WITHIN 35 DAYS AFTER FINAL PAYMENT FOR EACH PERIOD OF DISABILITY.

11. NUMBER OF DAYS BENEFITS

12. BENEFITS PAID THROUGH

13. TOTAL AMOUNT OF BENEFITS

14. TOTAL AMOUNT DIVERTED TO

PAID

 

PAID

SATISFY SUPPORT OBLIGATION

 

 

$

$

 

 

 

 

15.CLAIM STATUS (CHECK ALL APPROPRIATE)

BENEFITS EXHAUSTED

RECOVERED / RETURNED TO WORK

BENEFITS NOT EXHAUSTED

ADJUSTMENT

BENEFITS DENIED (ATTACH DENIAL LETTER)

16.(REQUIRED) TYPE OR PRINT NAME OF PERSON COMPLETING FORM

17.TELEPHONE NUMBER

()

18.DATE

SUBMIT COMPLETED FORM AS FOLLOWS:

 

INTERNET OR HARDCOPY VERSION:

PRINT AND MAIL TO: VOLUNTARY PLAN GROUP, MIC 29VP

 

P.O. BOX 826880

 

SACRAMENTO, CA 94280-0001

 

(PLEASE DO NOT ATTEMPT TO E-MAIL THE INTERNET VERSION.)

WORD VERSION:

E-MAIL TO: VOLUNTARY PLAN GROUP, vp2523@edd.ca.gov

IN THE AREA BELOW, ENTER THE NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYER OR PLAN ADMINISTRATOR IF REQUESTING STATE AWARD INFORMATION.

DE 2523 Rev. 19 (1-13) (INTERNET)

Page 1 of 2

CU

INSTRUCTIONS FOR COMPLETING THE

REPORT OF VOLUNTARY PLAN DISABILITY CLAIM, DE 2523

Complete items 1-10 and 16-18 and return within 15 days after the receipt of a first claim for disability benefits (California Code of Regulations, title 22, section 3267-1).

1.Enter all digits of the claimant’s social security number.

(A claim cannot be processed without an accurate number. The use of an incorrect number can result in erroneous notices to the claimant and employer.)

2.Enter the claimant’s full name.

3.Enter the date the disability began.

4.Enter the claimant’s current mailing address.

5.Enter a check mark in the appropriate box.

6.Enter the month, day, and year of claimant’s date of birth.

7.Enter the six digit voluntary plan number.

8.Enter the employer's name.

9.Enter the physician’s diagnosis or International Classification of Diseases (ICD) Code.

10.Enter an “X” in the appropriate box. If yes is checked, the Department will mail the award information to the address provided.

Complete items 11-18 and return within 35 days after final payment for each period of disability (California Code of Regulations, title 22, section 3267-1).

11.Enter the number of days disability benefits were paid.

(Includes days paid under a supplemental accident and sickness plan or salary continuance only if they are part of the Voluntary Plan.)

12.Enter the last date for which disability benefits were paid by the voluntary plan.

13.Enter the amount of disability benefits paid from the voluntary plan.

(Enter the amount paid for the days entered in item 11. Include any amount withheld for support obligation.)

14.Enter the amount of disability benefits that were diverted to satisfy a support obligation.

(Enter the amount of benefits withheld under the Support Intercept Program. This amount must be included in the total of item 13.)

15.Enter an “X” in the boxes that apply to the current claim status. Benefits Exhausted: The total maximum award has been paid.

Benefits Not Exhausted: A balance of the maximum benefit amount remains.

Benefits Denied: No benefits have been paid. A copy of the denial letter to the claimant must be electronically attached or submitted under separate cover.

Recovered/Return to Work: The claimant has recovered from the disability and/or returned to work.

Adjustment: Use if submitting an amended report.

16.Enter the printed name of the person completing the form.

17.Indicate the telephone number of the person completing the form.

18.Enter the current date.

In the space provided at the bottom of the page, type or print clearly the name and mailing address of the employer or the third party administrator.

SUBMIT COMPLETED FORM AS FOLLOWS:

INTERNET or HARDCOPY VERSION

WORD VERSION

PRINT and MAIL TO:

E-MAIL TO:

Voluntary Plan Group, MIC 29VP

Voluntary Plan Group, vp2523@edd.ca.gov

 

P.O. Box 826880

You may also print and mail your report to:

Sacramento, CA 94280-0001

Voluntary Plan Group, MIC 29VP

 

(Please do not attempt to e-mail the Internet version.)

P.O. Box 826880

 

Sacramento, CA 94280-0001

 

 

DE 2523 Rev. 19 (1-13) (INTERNET)

Page 2 of 2

How to Edit Form De 2523 Online for Free

Form De 2523 can be completed easily. Simply make use of FormsPal PDF editing tool to accomplish the job quickly. Our tool is continually evolving to give the best user experience possible, and that's due to our dedication to continuous enhancement and listening closely to customer opinions. Here's what you'd need to do to start:

Step 1: Firstly, open the pdf tool by pressing the "Get Form Button" above on this webpage.

Step 2: With the help of this handy PDF tool, you can actually do more than simply complete blank fields. Edit away and make your docs appear faultless with customized textual content put in, or modify the file's original input to perfection - all that comes with an ability to add any graphics and sign the PDF off.

When it comes to fields of this specific PDF, this is what you need to know:

1. To start with, while filling out the Form De 2523, begin with the page that has the subsequent blank fields:

Form De 2523 writing process described (part 1)

2. The subsequent stage is usually to fill in these particular fields: COMPLETE ITEMS AND SUBMIT, TOTAL AMOUNT OF BENEFITS, BENEFITS PAID THROUGH, TOTAL AMOUNT DIVERTED TO, PAID, CLAIM STATUS CHECK ALL APPROPRIATE, PAID, SATISFY SUPPORT OBLIGATION, BENEFITS EXHAUSTED, BENEFITS NOT EXHAUSTED, BENEFITS DENIED ATTACH DENIAL, RECOVERED RETURNED TO WORK, ADJUSTMENT, REQUIRED TYPE OR PRINT NAME OF, and TELEPHONE NUMBER.

Step no. 2 for filling in Form De 2523

3. The third step is usually straightforward - fill out all the blanks in PRINT and MAIL TO, EMAIL TO, Voluntary Plan Group MIC VP PO Box, Please do not attempt to email the, Voluntary Plan Group vpeddcagov, You may also print and mail your, Voluntary Plan Group MIC VP PO Box, DE Rev INTERNET, and Page of to conclude this process.

Filling in part 3 of Form De 2523

Be extremely careful when filling out DE Rev INTERNET and You may also print and mail your, since this is where a lot of people make a few mistakes.

Step 3: Be certain that the information is correct and then just click "Done" to conclude the task. Try a free trial plan with us and obtain instant access to Form De 2523 - with all transformations saved and accessible inside your personal cabinet. When using FormsPal, you're able to complete documents without the need to be concerned about personal data breaches or entries getting distributed. Our protected software makes sure that your private data is stored safe.

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