Guide for Completing a Claim Form for Paid Family Leave (PFL) Benefits

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GUIDE FOR COMPLETING A CLAIM FORM FOR

PAID FAMILY LEAVE (PFL) BENEFITS

State Disability Insurance (SDI) offers secure and convenient online options for ﬁling Paid Family Leave (PFL) claims.

For faster processing, submit a claim form and documentation on SDI Online (edd.ca.gov/SDI_Online).

To avoid delays when ﬁling a claim using the paper application, please follow the general guidelines below. Allow

sufﬁcient time for claim processing (generally two weeks). For more information, read the yellow instruction and

information sheet provided with the Claim for Paid Family Leave (PFL) Beneﬁts (DE 2501F) contact the PFL ofﬁce at

1-877-238-4373, or visit State Disability Insurance (edd.ca.gov/disability).

Claim Type PFL provides beneﬁts to eligible workers who need to take time off work to care for a

seriously ill family member, to bond with a new child, or to participate in a qualifying

event as a result of a family member’s military deployment to a foreign country. Do not

ﬁle for more than one claim type on the same claim form or for the same period of time.

Bonding with a New

Baby after a Disability

Insurance (DI)

Pregnancy-Related

Claim

For new mothers who received pregnancy-related DI beneﬁts prior to ﬁling for PFL

beneﬁts.

• The Claim for Paid Family Leave (PFL) Beneﬁts – New Mother (DE 2501FP) will

automatically be mailed to you in a separate envelope at the end of your DI claim

after your ﬁnal payment is issued.

• When you have recovered from delivering your baby, submit your Claim for Paid

Family Leave (PFL) Beneﬁts – New Mother (DE 2501FP).

• Complete all sections of the Claim for Paid Family Leave (PFL) Beneﬁts – New

Mother (DE 2501FP), and mail no later than 41 days from the date you wish to begin

your bonding claim or you may submit it using SDI Online.

• If you do not receive this form, call DI at 1-800-480-3287 or PFL at 1-877-238-4373.

Bonding with a

New Child

For new mothers without a prior pregnancy-related disability claim, new fathers,

registered domestic partners, or foster care or adoptive parents.

• Complete and sign Part A on page 1 and Part B on page 3 of the Claim for Paid

Family Leave (PFL) Beneﬁts (DE 2501F), and mail no later than 41 days from the date

you wish to begin your bonding claim.

• Include Proof of Relationship documentation with your bonding claim.

Birth veriﬁcation must clearly show the child’s name, date of birth, gender, and

the name of the parent claiming beneﬁts.

New placement of foster care or adoption documentation must verify the date

the child was placed in your custody.

• Bonding beneﬁts are payable within one year of the child’s birth or placement, if

eligible.

Care To provide care for a seriously ill child, parent, parent-in-law, grandparent, grandchild,

sibling, spouse, or registered domestic partner.

• Submit a Claim for Paid Family Leave (PFL) Beneﬁts (DE 2501F):

Complete and sign Part A on page 1.

Have the care recipient complete Part C on page 3.

Have the care recipient’s physician/practitioner complete and sign Part D on page 4.

• If the care recipient cannot complete and sign Part C on page 3 due to their

disability, or if you are an authorized representative ﬁling for beneﬁts on behalf of an

incapacitated or deceased claimant, call 1-877-238-4373 for instructions and

required forms prior to submitting a claim. Parts A, C, and D are required to be

considered a complete claim.

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For additional information, please visit State Disability Insurance (edd.ca.gov/disability).

The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to

individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling

1-866-490-8879 (voice) or through the California Relay Service at 711.

These guidelines are for general information only and do not have the force and effect of law, rule, or regulation.

Military Assist To participate in a qualifying event as a result of a spouse, registered domestic

partner, parent, or child’s military deployment to a foreign country.

• Complete and sign Part A on page 1 and Part E on pages 5 and 6 of the Claim for

Paid Family Leave (PFL) Beneﬁts (DE 2501F), and mail no later than 41 days from

the date you wish to begin your military assist claim.

• Proof of covered active duty or call to covered active duty of the family member

(listed in Box E10) must be attached along with documentation that supports the

qualifying event for leave.

Partial Beneﬁts If you have reduced your work schedule and have a wage loss.

• Please mark “yes” on the Claim for Paid Family Leave (PFL) Beneﬁts (DE 2501F),

question A13 or on the Claim for Paid Family Leave (PFL) Beneﬁts – New Mother,

(DE 2501FP), question 6 if you continue to work during your family care leave.

• Attach a separate letter if you will be working part-time or taking leave on an

intermittent basis. Be sure to include your Social Security number, name, address,

phone number, regular working hours, rate of pay, and the amount of time you

plan to be off work each week.

Wages from your

Employer

If your employer continues to pay you wages during your claim.

If your employer pays you the difference between PFL beneﬁts and full pay, write

“INTEGRATE” on the Claim for Paid Family Leave (PFL) Beneﬁts (DE 2501F), question

A22 or on the Claim for Paid Family Leave (PFL) Beneﬁts – New Mother

(DE 2501FP), question 6.

Your Responsibilities Submit your claim and any other required forms completely, accurately, and in a

timely manner.

• Use black ink only.

• Do not separate the pages of the form, and submit all parts of the claim form at

one time.

• Submit the claim form when you begin your family leave claim. The EDD is

unable to process claims with future beginning dates.

• If submitting a claim form late, you must include a written explanation of the

reason(s) for the lateness to avoid a disqualiﬁcation.

• Mail your claim form in the pre-addressed envelope. If you do not have

the pre addressed envelope provided with the claim, send your claim and

correspondence to: EDD-Paid Family Leave, PO Box 989315, West Sacramento,

CA 95798-9315.

PFL Toll-Free Numbers English 1-877-238-4373

Spanish 1-877-379-3819

Cantonese 1-866-692-5595

Vietnamese 1-866-692-5596

Armenian 1-866-627-1567

Punjabi 1-866-627-1568

Tagalog 1-866-627-1569