Get the free De 2501 Rev. 78 (4-12) Pdf Form

DE 2501 Rev. 78 (412) PDF Form 2501 disability DE 2501 Rev. 78 412 Instruction Information Page 1 of 4 A CU BASIC ELIGIBILITY. DI benefits can be paid Sign PDF Electronically. DE 2501 Rev 78 4 12

How to fill out de 2501 rev 78

How to fill out de 2501 rev 78

1. To fill out the DE 2501 Rev 78 form, follow these steps:
2. Start by entering the name of the injured worker in the 'Employee's Name' field.
3. Provide the employee's Social Security number in the 'Social Security Number' field.
4. Fill in the 'Date of Injury/Last Exposure/Illness' field with the date when the injury or illness occurred.
5. Indicate the address where the injured worker should receive correspondence in the 'Mailing Address' field.
6. Specify the injured worker's occupation and employer's name in the respective fields.
7. Provide the contact information of the injured worker or their representative in the 'Contact Phone Number or Email' field.
8. Next, you need to describe the injury, illness, or condition in detail in the 'Nature of Injury or Illness and Part of Body Affected' field.
9. If the injured worker received any medical treatment, specify the name and address of the doctor or medical facility in the 'Physician Name/Address or Hospital/Clinic' field.
10. Fill in the 'Date First Treated' field with the date when the injured worker first received medical treatment.
11. Indicate the name and address of the insurance company that provided the workers' compensation insurance in the 'Insurance Carrier Name/Address' field.
12. Provide the injured worker's signature and date in the 'Employee's Signature' and 'Date' fields respectively.
13. Finally, ensure that all the required information is completed accurately and legibly before submitting the form.

Who needs de 2501 rev 78?

1. DE 2501 Rev 78 is needed by injured workers who have suffered from a work-related injury, illness, or condition.
2. This form is used to apply for workers' compensation benefits in California.
3. It is required for individuals who want to receive compensation for medical expenses, temporary or permanent disability benefits, or death benefits resulting from a work-related incident.
4. Employers may also need this form to report the injury or illness to their workers' compensation insurance carrier.

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