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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:
General Program:
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
Requestor’s Name: Title:
Organization Name:
Phone Number: Email:
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SECTION 3 Benefit Program Type
Check applicable box(es).
Disability Insurance Voluntary Plan Nonindustrial Disability Insurance
Paid Family Leave Elective Coverage
SECTION 4 Inquiry
1. Check applicable box(es) and provide specific year(s).
Quarter(s): _______________________________________________________
Month(s): ________________________________________________________
Fiscal Year(s): ____________________________________________________
Calendar Year(s): _________________________________________________
Other: _________________________________________________________________
Format Deliverable: Table Chart
2. Provide a detailed and succinct description of the information requested. Describe
how the information will be used. Attach a separate document, if necessary.
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3. Who is your target audience (e.g. general public, publication, etc.)?
4. Will this data be released to the public?
Yes No
If yes, provide the individual or group name(s), phone number(s), and address(es), and
how the information will be shared.