Self-Employed - DIEC Forms and Publications

Disability Insurance Elective Coverage Forms and Publications

Please use the links on this page to access informational forms, materials, and the application for Disability Insurance Elective Coverage.

Use a Computer to Fill In Forms
- Annual Income Report for Disability Insurance Elective Coverage - DE 945 Rev. 3 (12-05)
- Application for Disability Insurance Elective Coverage - DE 1378DI Rev. 41 (2-05)

Disability Insurance Elective Coverage Pamphlet
- DE 2565 Rev. 13 (1-10) - English
- DE 2565/S Rev. 13 (1-10) - Spanish
Disability Insurance Elective Coverage (DIEC) Rate Notice and Instructions for Computing Annual Premiums
- DE 3DI-I Rev. 50 (12-09)
Information Sheet
- Elective Coverage for Employers and Self-Employed Individuals - DE 231EC Rev. 7 (10-08)
Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts
- DE 2588 - Rev. 6 (1-10)
Disability Insurance (DI) and Paid Family Leave (PFL) Weekly Benefit Amounts in Dollar Increments
- DE 2589 - Rev. 3 (1-10)
Fact Sheets
- Disability Insurance Elective Coverage Program Fact Sheet - DE 8714CC Rev. 18 (12-09) - English
- Disability Insurance Elective Coverage Program Fact Sheet - DE 8714CC/S Rev. 18 (12-09) - Spanish