Cal. Code Regs. Tit. 22, §§ 2706-2

Current through Register 2024 Notice Reg. No. 50, December 13, 2024

Section 2706-2 - [Operative 1/1/2025] Claim for Family Temporary Disability Insurance Benefits - Filing and Contents

(a) "First claim" means the claim initially filed on a form prescribed by the department with respect to a 12-month period of family care leave. By filing the first claim, the claimant establishes his or her 12-month period and the department computes the weekly benefit amount and maximum benefits potentially payable for the 12-month period.

(b) Any individual who has taken time off from his or her work for purposes of family care leave, as defined in section 3302 of the code, may file a claim for benefits.

(c) A "properly completed first or re-established claim" means a claim containing all the required items as prescribed in subdivisions (d), (e), (f), and (g) of this section.

(d) The claimant shall file the first or re-established claim and shall provide his or her:

(1) legal name, and any other name(s) used by the claimant.

(2) social security account number, and any other names and social security account numbers by which the claimant is or was known.

(3) date of birth.

(4) gender.

(5) mailing address.

(6) driver license number or identification card number, provided that the driver license or identification card was issued by a local, state, or federal agency, or a foreign government.

(7) last day worked at his or her last job.

(8) reason why he or she is no longer working at his or her last job.

(9) occupation.

(10) name(s) and address(es) of his or her most recent employer(s).

(11) date on which he or she requests benefits to begin.

(12) care recipient's legal name.

(13) relationship to the care recipient. The claimant may be required to provide evidence of the relationship to the family member to support the claim such as a birth or marriage certificate or proof of a registered domestic partnership.

(14) statement attesting whether any other family member is ready, willing, and able and available to provide care or participate in a qualifying exigency as defined in section 3302.2 of the code for the same period of time in a day.

(15) signature.

(16) where the claimant is applying for benefits to care for a seriously ill child, spouse, parent, grandparent, grandchild, sibling, or domestic partner, authorization for the department to disclose the claimant's information as listed herein from (d)(1) to (d)(15) to the care recipient's treating physician or practitioner and to the care recipient.

(17) such other information within the scope of eligibility requirements as the department may require.

(e) The claimant shall complete the bonding certification if applying for benefits to bond with a new child and shall set forth the new child's:

(1) social security account number, if issued. Absence of child's social security account number shall not disqualify the claimant.

(2) relationship to the claimant.

(3) date of foster care, guardianship, or adoption placement of the new child with the claimant or family member.

(4) legal name.

(5) date of birth.

(6) gender.

(7) residence address.

(8) documentary evidence, pursuant to section 2708(c)-1 of these regulations.

(9) claimant's signature.

(10) such other information as the department may require.

(f) The claimant shall also provide the information as specified below about the following persons if applying for benefits to care for a seriously ill child, spouse, parent, grandparent, grandchild, sibling, or domestic partner:

(1) for a care recipient, the claimant shall provide the care recipient's:

(A) legal name.

(B) social security account number, if issued. Absence of care recipient's social security account number shall not disqualify the claimant.

(C) date of birth.

(D) gender.

(E) residence address.

(F) signature or authorized representative's signature authorizing the treating physician or practitioner to release the care recipient's protected health information to the department and the claimant.

(2) The claimant shall gather from the treating physician or practitioner on the department's designated form:

(A) the name of the care recipient.

(B) the date of birth of the care recipient.

(C) a diagnosis and diagnostic code(s) prescribed in the International Classification of Diseases, or where no diagnosis has yet been obtained, a detailed statement of symptoms.

(D) the date, if known, on which the serious health condition of the care recipient commenced.

(E) the probable duration of the care recipient's serious health condition.

(F) an estimate of the duration of time that the care provider is needed to care for the care recipient.

(G) the number of hours per day that the care provider is needed to care for the care recipient.

(H) a statement that the care recipient's serious health condition warrants the participation of the care provider to provide care for the care recipient.

(I) a statement regarding whether disclosure of the doctor's certification would be medically or psychologically detrimental to the care recipient.

(J) the treating doctor's or practitioner's name and address.

(K) the treating doctor's or practitioner's license number.

(L) the treating doctor's or practitioner's signature.

(M) such other information within the scope of eligibility requirements as the department may require.

(g) If applying for benefits to participate in a qualifying exigency as provided in section 3302.2 of the code, the claimant shall complete the military assist certification, which includes the following information:

(1) social security account number of the claimant.

(2) legal name (first name, middle initial, last name) used by the claimant.

(3) name of the military member on covered active duty or impending call to covered active duty status.

(4) date of birth and gender of the military member.

(5) mailing address of the military member.

(6) the last four digits of the military member's social security account number.

(7) the beginning and ending dates of the military member's covered active duty.

(8) the date on which the military member was notified of the impending call or order to covered active duty.

(9) a copy of the military member's covered active duty order, a copy of the letter notifying the military member of the impending call or order to covered active duty, or documentation of the military leave signed by the approving authority for the military member's rest and recuperation.

(10) the qualifying event for which the claimant is requesting Paid Family Leave benefits.

(11) written documentation supporting the request for leave. If leave is requested to meet with a third party, the claimant must provide written documentation of the meeting that includes the name, address, and contact information of the individual or entity with whom the claimant is meeting.

(12) claimant's signature, date of signature, and attestation to the following statement: "By my signature on this military assist certification, I understand that willfully making a false statement or knowingly failing to disclose a material fact in order to obtain payment of benefits is a violation of California law punishable by imprisonment or fine or both. I declare under penalty of perjury that the foregoing statement, including any accompanying statements or documents, is to the best of my knowledge and belief true, correct, and complete. I agree that photocopies of this authorization shall be as valid as the original, and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of the claim, whichever is later."

(13) such other information within the scope of eligibility requirements as the department may require.

Cal. Code Regs. Tit. 22, §§ 2706-2

Note: Authority cited: Sections 305 and 306, Unemployment Insurance Code. Reference: Sections 2701.5, 2706 and 3303.1, Unemployment Insurance Code.

1. New section filed 6-23-2004; operative 7-1-2004 pursuant to Government Code section 11343.4 (Register 2004, No. 26). For prior history, see Register 69, No. 52.
2. Amendment of subsections (a)-(b) filed 11-6-2008; operative 12-6-2008 (Register 2008, No. 45).
3. Amendment of subsections (c) and (d)(1)-(2), new subsections (d)(2)(A)-(B) and (d)(6), subsection renumbering and amendment of newly designated subsections (d)(16)-(17), (e)(3) and (f)(2)(M) filed 9-16-2011; operative 10-16-2011 (Register 2011, No. 37).2706-7
4. Change without regulatory effect amending subsection (b) filed 1/10/2017 pursuant to section 100, title 1, California Code of Regulations (Register 2017, No. 2).
5. Change without regulatory effect amending subsection (b) filed 12-5-2017 pursuant to section 100, title 1, California Code of Regulations; effective 1/1/2018 (Register 2017, No. 49).
6. Amendment filed 9-26-2024; operative 1/1/2025 (Register 2024, No. 39).