ID-11B Notice of Insufficient Medical and Late Filing

CURTZE~JT

UNITEDSTATESOF AMERICA

RAILROADRETIREMENT
BOARD

Form Approved
OMB No. 3220-0039

OFFICEOF PROGRAMS
- OPERATIONS
P.O. Box 10695
CHICAGO,IL 606 11-0695

In reply refer to
Name:
SS No.:
REQ:
NOI-ICE OF INSUFFICIENT MEDICAL AND LATE FILING
We received your Application for Sickness Benefits for your infirmity of
. The Statement of
Sickness, which accompanied your application, indicates that you were first seen by your doctor on
, for this infirmity. Consequently, sickness benefits cannot be paid for the days
, because there is no medical evidence supporting your inability to work during that
through
period.
If you were treated or under a doctor's care for the above period, please submit a signed statement
from your doctor indicating your dates of treatment, diagnosis, and subsequent follow-up
treatments. This information may be provided on forms containing the doctor's letterhead.
In addition, your Application for Sickness Benefits and Statement of Sickness were not received
within the 10-day time limit as prescribed under the Railroad Unemployment Insurance Act (RUIA).
Since we could not tell why your form was filed late, we can start your benefits no earlier than
. Please complete the next page and return this entire notice with your additional medical
information. We will either start your benefits with an earlier date or notify you of why your benefits
cannot begin earlier.
If you disagree with this determination and do not wish to furnish additional medical evidence or an
explanation for late filing, you may file a written request for reconsideration. Your request must be
received at an office of the Railroad Retirement Board (RRB) within 60 days from the date of this
letter.
Sincerely,

(Continued On Next Page)

Form Approved
OMB NO. 3220-0039

REPLY TO NOTICE OF LATE FILING

1. What actions did you take to obtain your Application for Sickness Benefits and Statement of
Sickness forms? Provide the dates these actions were taken.

2. What steps did you take to complete these forms and file them with the Railroad Retirement
Board? Provide the dates these steps were taken.

3. Provide the names and titles of any persons who helped you complete and file the forms.

4. Do you wish to claim as days of sickness all days for which you may be entitled to benefits prior
to MM-DD-YY?
YES - Go to ltem 6
NO

5. Enter any days you do not wish to claim.
6. Will you receive wages or other pay (other than these benefits) for your days of sickness?
NO - Go to ltem 10
YES
7. What kind of wages or other pay will you receive?

8. List the exact days for which you will receive any such payments.
9. Who will make these payments?

10. CERTIFICATION: I know that disqualifications and civil and criminal penalties may be imposed
on me for false or fraudulent statements or claims or for withholding information to get benefits
from the Railroad Retirement Board. I affirm that the information given on this form is true,
correct, and complete.
SIGNATURE

DATE

Return this form to the RRB address shown at the top of the other side of this letter.

The RRB is authorized to collect the information requested on this form under Section 5(b) of the
RUIA. Although you are not required to provide the information, failure to do so could result in a
loss of benefits to you. We estimate this form takes an average of 3 minutes to complete, including
time for reviewing the instructions, getting the needed data, and reviewing the completed form.
Federal agencies may not conduct or sponsor, and respondents are not required to respond to, a
collection of information unless it displays a valid OMB number. If you wish, send comments
regarding the accuracy of our estimate or any other aspects of the form, including suggestions for
reducing completion time, to the Chief of Information Management, Railroad Retirement Board,
844 N. Rush Street, Chicago, IL 6061 1-2092.