DE 2541E Rev. 1 (2-18) (INTERNET) Page 1 of 3 CU
State Disability Insurance
Request for Information Form
The State Disability Insurance program is committed to providing quality service and
timely delivery of information requested. To better serve you, please complete this form to
help collect important information needed to process your request. A monetary charge
may be applied based on the time and complexity associated with delivering the request.
Instructions: Complete each applicable section to submit an inquiry for data or program
information. If the inquiry contains multiple components, use only one form and the
general program email address.
Depending on the type of inquiry, send the form to the appropriate email address:
• Data: DIDataReq@edd.ca.gov
• General Program: DIBOutreach@edd.ca.gov
SECTION 1 – Requestor’s Contact Information
SECTION 2 – Request Type
Check applicable box(es)
Program Data (data and statistics only)
General Program Information (e.g. history, department policies, eligibility, etc.)
Date: Due
Date:
Requestor’s Name: Title:
Organization Name:
Phone Number: Email: