NOTICE OF APPEAL AND PETITION FOR DISABILITY INSURANCE BENEFITS REVIEW
(California Administrative Proceeding – State Disability Insurance or Private Disability Policy)
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Parties
• Appellant: [APPELLANT LEGAL NAME], an individual claimant residing at [ADDRESS] (“Appellant”).
• Respondent: [CALIFORNIA EMPLOYMENT DEVELOPMENT DEPARTMENT / NAME OF PRIVATE INSURER] (“Respondent”).
• Administrative Tribunal: [CALIFORNIA UNEMPLOYMENT INSURANCE APPEALS BOARD / NAME OF DESIGNATED ADMINISTRATIVE BODY] (“Tribunal”).
1.2 Determination Under Review
• Date of Determination: [MM/DD/YYYY]
• Determination/Claim No.: [NUMBER]
• Benefit Type: [STATE DISABILITY INSURANCE (“SDI”) / SHORT-TERM DISABILITY / LONG-TERM DISABILITY]
1.3 Effective Date
This Notice of Appeal and Petition (“Appeal”) is effective as of the date executed below (the “Effective Date”).
1.4 Jurisdiction & Governing Law
This Appeal is governed by the laws and regulations of the State of California relating to disability insurance benefits, including but not limited to Cal. Unemp. Ins. Code §§ 2601 et seq., and shall be adjudicated exclusively in the designated administrative forum.
1.5 Recitals
WHEREAS, Respondent issued the Determination denying, terminating, or modifying Appellant’s disability insurance benefits;
WHEREAS, Appellant timely seeks review pursuant to Cal. Unemp. Ins. Code § 2707.4 (20-day appeal period for SDI determinations) and other applicable law; and
WHEREAS, Appellant desires to perfect this Appeal and set forth supporting grounds, evidence, and requested relief.
NOW, THEREFORE, Appellant respectfully petitions the Tribunal as follows:
2. DEFINITIONS
For purposes of this Appeal, the following capitalized terms shall have the meanings set forth below:
“Administrative Record” – The complete file held by Respondent relating to Appellant’s claim, including medical certifications, vocational assessments, correspondence, and determinations.
“Benefit Amount” – The weekly or monthly disability benefit payable under the governing statute or policy, capped at [DOLLAR AMOUNT] per [WEEK/MONTH] (“Liability Cap”).
“Disability” – Any physical or mental condition that renders a person unable to perform regular or customary work, as defined in Cal. Unemp. Ins. Code § 2626.
“Medical Evidence” – Physician certificates, treatment records, diagnostic tests, and expert opinions establishing the nature, severity, and expected duration of Appellant’s Disability.
“Vocational Factors” – Appellant’s age, education, work history, transferable skills, and labor-market data relevant to employability and functional capacity.
3. OPERATIVE PROVISIONS
3.1 Timeliness of Appeal
Appellant affirms this Appeal is filed within the statutory deadline of twenty (20) calendar days from service of the Determination (Cal. Unemp. Ins. Code § 2707.4) or within any extended period permitted for good cause.
[// GUIDANCE: Adjust to 30-day window for private policies or as policy dictates.]
3.2 Grounds for Appeal
(a) Erroneous Medical Assessment – Respondent failed to credit substantial Medical Evidence confirming ongoing Disability.
(b) Inadequate Consideration of Vocational Factors – Respondent disregarded Appellant’s inability to perform past or alternative work.
(c) Procedural Error – Respondent violated due-process requirements by [e.g., lack of notice, failure to obtain independent medical review].
(d) Statutory/Policy Misinterpretation – Respondent misapplied governing provisions by [DESCRIPTION].
3.3 Relief Requested
(i) Reversal of the Determination;
(ii) Immediate reinstatement or payment of retroactive and prospective benefits;
(iii) Award of statutory interest;
(iv) Any further relief deemed just and proper.
3.4 Submission of Evidence
Appellant hereby submits, and incorporates by reference, the Medical Evidence listed in Schedule A and Vocational Evidence in Schedule B.
[// GUIDANCE: Attach exhibits with clear indexing; include treating physician declarations and functional capacity evaluations.]
3.5 Hearing Request
Appellant requests an in-person or virtual hearing before an Administrative Law Judge (“ALJ”) and the right to present testimony, cross-examine witnesses, and offer additional evidence.
3.6 Conditions Precedent
Appellant has complied with all policy notice provisions, premium requirements (if applicable), and statutory prerequisites to appeal.
4. REPRESENTATIONS & WARRANTIES
4.1 Accuracy of Information
Appellant represents that all statements, facts, and evidence provided herein are true, complete, and accurate to the best of Appellant’s knowledge.
4.2 Authenticity of Exhibits
Appellant warrants that each exhibit is a true and correct copy of the original and is admissible pursuant to the California Evidence Code and administrative-hearing rules.
4.3 Survival
The representations and warranties in Sections 4.1–4.2 survive final disposition of this Appeal.
5. COVENANTS & RESTRICTIONS
5.1 Ongoing Cooperation
Appellant covenants to:
(a) Supplement Medical Evidence upon reasonable request;
(b) Appear for independent medical examinations scheduled in accordance with statutory safeguards;
(c) Notify the Tribunal and Respondent of any material change in medical or vocational status within ten (10) business days.
5.2 Non-Retaliation
Respondent shall not terminate or modify benefits, or otherwise retaliate, solely due to Appellant’s exercise of appeal rights.
6. DEFAULT & REMEDIES
6.1 Events of Default
(a) Untimely Appeal filing (by either party relative to subsequent decisions);
(b) Failure to comply with discovery or evidence-exchange orders;
(c) Failure to appear at scheduled hearings without good cause.
6.2 Notice & Cure
Upon occurrence of an Event of Default, the non-defaulting party shall provide written notice. The defaulting party shall have ten (10) calendar days to cure, unless the ALJ orders otherwise.
6.3 Remedies
(a) Dismissal of Appeal (if Appellant defaults);
(b) Preclusion of late evidence;
(c) Entry of adverse inference or sanctions consistent with administrative rules;
(d) Award of attorney’s fees and costs where authorized by statute or policy.
7. RISK ALLOCATION
7.1 Indemnification
Not applicable; no third-party indemnity is created or required in this administrative proceeding.
7.2 Limitation of Liability
Any monetary liability of Respondent is capped at the Benefit Amounts recoverable under the governing statute or insurance policy, plus statutory interest, attorney’s fees, and costs where awarded (“Liability Cap”).
7.3 Force Majeure
Should extraordinary circumstances (e.g., natural disaster, declared emergency) prevent compliance with procedural timelines, the affected party may request equitable tolling or continuance.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Appeal shall be construed in accordance with California state disability insurance law, Cal. Unemp. Ins. Code §§ 2601 et seq., and related regulations.
8.2 Forum Selection
Exclusive jurisdiction lies with the Tribunal as the administrative court of competent jurisdiction.
8.3 Arbitration
Not available; matters are to be adjudicated in the administrative forum.
8.4 Jury Waiver
By statute, no jury trial is available in administrative disability proceedings.
8.5 Injunctive Relief
Appellant reserves the right to seek interim benefit payment or other equitable relief where authorized, to prevent irreparable harm.
9. GENERAL PROVISIONS
9.1 Amendments & Waivers
Any amendment to this Appeal must be in writing and filed with the Tribunal; waivers require express ALJ approval.
9.2 Assignment
Neither party may assign rights or obligations arising from this Appeal without prior written consent and Tribunal approval.
9.3 Severability
If any provision herein is held unlawful or unenforceable, the remaining provisions shall remain in full force, and the Tribunal may reform the provision to the minimum extent necessary.
9.4 Integration
This document, together with all attached Schedules and evidence, constitutes the complete statement of Appeal grounds and supersedes prior submissions.
9.5 Electronic Filing & Signature
This Appeal may be executed and filed electronically in compliance with Tribunal rules; electronic signatures shall be deemed original.
10. EXECUTION BLOCK
Executed under penalty of perjury under the laws of the State of California.
Date: [MM/DD/YYYY]
Location: [City], California
[APPELLANT NAME]
Appellant
[// GUIDANCE: For corporate insurers, add corporate signature block with officer title and verification per Cal. Code Regs. Tit. 22.]
Notary Acknowledgment: [REQUIRED / WAIVED per Tribunal e-filing rules]
SCHEDULE A – MEDICAL EVIDENCE
- Treating Physician Certificate – Dr. [NAME], dated [DATE]
- MRI Report – [DATE]
- Functional Capacity Evaluation – [DATE]
- [ADDITIONAL RECORDS]
SCHEDULE B – VOCATIONAL EVIDENCE
- Vocational Expert Report – [NAME], dated [DATE]
- Occupational Job Analysis – [DATE]
- Labor-Market Survey – [DATE]
[// GUIDANCE: Number each exhibit consecutively; provide summaries for easy reference at hearing.]