Sickness Benefits for Railroad Employees

Sickness Beneffi
Appfication Enclosed

Sickness Benefits
for
Railroad Employees

United States of America
Railroad Retirement Board
Visit our Web site at http://www.rrb.gov

Form UB-11 (11-06)

CONTENTS

Introduction

....................................................................................

1

Reconsideration a n d Waiver
Employee Rights ................................................................ 5

Qua1ification Requirements ...............................................

2

A m o u n t a n d Duration o f Benefits
W a i t i n g Period

....................................................................

N o r m a l Benefits

...................................................................

Extended Benefits

...............................................................

Accelerated Benefits
D a i l y Benefit Rate

.........................................................

..............................................................

N u m b e r o f Days o f Sickness

....................................

Tier I Tax Deductions .......................................................

5

Employer Rights .......................................................
W h e n Sickness Benefits are Taxable

5

.............................

2
2
2
2
3
3
3

lnstructions f o r C o m p l e t i n g Forms

5
5

General Instructions .......................................................
I m p o r t a n t I n f o r m a t i o n .................................................
Application f o r Sickness
Benefits (SI-la)

6

....................................................................

Statement o f Sickness (SI-1 b)

....................................

8

...................................

8

Statement o f A u t h o r i t y
E l i g i b i l i t y Requirements .........................................................

3

t o A c t f o r Employee (SI-10)

C l a i m f o r Sickness Benefits (SI-3)
M e d i c a l Statements ......................................................................

........................

8

3
Notices

Sick Pay a n d Supplemental

Privacy A c t

Sickness Benefits .......................................................................

4

....................................................................

Computer M a t c h i n g a n d Privacy
Protection A c t

Disqualifications

10

................................................................

Paperwork Reduction A c t .......................................

10
11

Nondiscrimination o n t h e Basis

.....................................................

4
4
4
4

RRB H e l p L i n e .................................................................................

12

Benefit Reductions ........................................................................

4

I m p o r t a n t Reminders .........................................................

13

Separation Allowance

.....................................................

False o r Fraudulent C l a i m

.........................................

Benefits U n d e r Other L a w s ......................................
Medical Examination

Personal Injury Settlements ................................................. 4

. . .

o f D ~ s a b ~ .........................................................................
l~ty

11

Fraud a n d A b u s e H o t L i n e ..............................................13

IF YOU ARE SICK OR INJURED, y o u m a y be eligible t o receive sickness benefits
f r o m t h e Railroad Retirement Board (RRB). This booklet provides i n f o r m a t i o n about
t h e requirements f o r receiving sickness benefits, t h e a m o u n t o f benefits payable, a n d
procedures f o r claiming benefits.

To receive sickness benefits, y o u m u s t complete a n d file t h e enclosed Form SI-la/b,
Application for Sickness Benefits, within 10 days f r o m t h e first d a y y o u w a n t t o c l a i m
benefits. An application is considered f i l e d o n t h e d a y it is received b y t h e RRB; if y o u
f i l e late y o u m a y lose benefits.
For other qualifications f o r sickness benefits see "Eligibility Requirements" o n page 3.
You may be able t o receive unemployment benefits if y o u are able t o w o r k b u t unemployed.
Those benefits are described in a separate booklet, UB-10, Unemployment Benefitsfor Railroad

Employees.
IMPORTANT: If there is no application enclosed with this booklet or you wish to obtain a
copy of the booklet UB-10, contact any RRB ofice, your railroad employer, your labor organization, a union official or the RRB1s W e b site at www.rrb.gov.

'

This booklet contains general information a n d does n o t have the effect o f law, regulation,
o r ruling. Certain exceptions, limitations, a n d special cases are n o t covered. If y o u have
a n y questions about sickness o r unemployment benefits, contact the nearest office o f the
RRB. W h e n w r i t i n g t o the RRB, be sure t o include y o u r social security number.
Spanish translation booklets concerning railroad sickness a n d unemployment benefits
are available f r o m a n y office o f t h e RRB.

Tenemos un librete en Espanol que explica 10s beneficios de 10s enfermos del ferrocarril.
Para obtener una copia, entre en contact0 con cualquier oficina de la RRB, su empleador
ferroviario, su organization laboral, un oficial de un sindicato o otraves del web site
RRB: www.rrb.sov.

Qualification Requirements
Base Year

- Benefit Year

Only qualified employees can receive benefits under the
Railroad Unemployment Insurance Act. A new benefit
year begins every July 1. To qualify for benefits in a benefit year, y o u must have creditable railroad earnings in the
preceding calendar year (base year), counting no more
than a certain amount i n any month. In addition, a new
employee must have railroad service in at least 5 months
o f his or her first year of work in order t o be eligible for
benefits in the following benefit year.
The amount o f earnings needed t o qualify for benefits in a
benefit year depends o n the monthly compensation base
in the base year. An employee is required t o have base
year earnings o f not less than 2-1/2 times the monthly
compensation base applicable to months in that base year.
As the monthly compensation base increases, the amount
o f compensation needed t o q u a l i f y f o r benefits also
increases.
Example
Benefit Year Beginning July 1,2005
Earnings Needed in Base Year-$2,825.00

I f y o u have at least 4 consecutive days o f sickness and 5
days o f sickness overall, y o u s h o u l d f i l e a c l a i m f o r
benefits. Even though no benefits may be payable if the
claim is your first claim in the benefit year, your claim
m u s t be f i l e d in order t o satisfy t h e w a i t i n g p e r i o d
requirement. If y o u have more than 7 days of sickness in
your waiting period claim, benefits w i l l be paid for the
number o f days o f sickness over 7. After your first claim,
benefits w i l l be paid for all days over 4 for other claims in
the benefit year.

A "period o f continuing sickness" means either (1) a perio d of consecutive days o f sickness, whether from one or
more causes, or (2) a period of successive days of sickness
due to a single cause without interruption of more than 90
consecutive days which are not days o f sickness.

Normal Benefns
Y o u can receive normal benefits f o r as m a n y as 130
days (26 weeks) in a benefit year, b u t y o u r benefits
cannot be more than y o u r base year wages counting
n o t m o r e t h a n a prescribed a m o u n t for a n y month.
Benefit rights are exhausted w h e n a benefit year ends
(normally June 30) or earlier if benefit payments equal
base year creditable earnings.

in 2004 (2-1/2

-x $1,130.00= $2,825.00). If2004 was your jirst year of rail-

road work, you must also have railroad service in 5 months in
2004.
I n this example, $1,130.00 is the monthly compensation
base for base year 2004. The monthly compensation base
for base year 2005 is $1,150.00.
Contact y o u r local RRB 'field office if y o u need inform a t i o n a b o u t t h e m o n t h l y c o m p e n s a t i o n base f o r
other years.

Amount and Duration
of Benefits
Waiting Period
To satisfy a one-week waiting period requirement, n o
benefits are payable for your first 7 days o f sickness in
y o u r f i r s t c l a i m in a p e r i o d o f c o n t i n u i n g sickness,
unless y o u have already served a waiting period i n the
benefit year. Benefits are payable for each remaining
day o f sickness in your first claim. For example, if y o u
claim all 14 days in y o u r first claim, y o u w i l l be p a i d
benefits for 7 days. I f y o u are eligible and y o u r claims
are continuous f r o m one benefit year t o another, y o u
generally w i l l serve o n l y one w a i t i n g period in y o u r
period o f continuing sickness.

Example
For purposes o f determining maximum normal benefits
payable in the general benefit year beginning July 1, 2005,
m o n t h l y earnings o f up t o $1,460.00 are counted for
months in base year 2004. For base year 2005, the monthly
compensation base for maximum benefits is $1,485.00.

Extended Benefits
I f you have 10 or more years o f service and exhaust your
normal sickness benefits, y o u m a y be eligible t o receive
extended benefits for up t o 65 days (7 consecutive 14-day
claim periods having 10 days payable in each). Also, if you
are not qualified for benefits i n the current benefit year, but
received normal benefits in the previous year, you may still
be eligible for extended benefits.
T o qualify for extended benefits, y o u must not have volu n t a r i l y retired. Extended sickness benefits are n o t
payable once y o u attain age 65.

Accelerated Benefns
Under certain special provisions, if y o u have 10 or more
years of service, y o u can receive benefits before the regular
beginning date o f a benefit year. To qualify, you must be
qualified for the next benefit year, but not the current year.
You must also have 14 or more consecutive days of sickness and not have voluntarily retired. Accelerated sickness
benefits are not payable once y o u attain age 65.

Daily Benefit Rate

the section Sick Pay a n d Supplemental Sickness

Your daily benefit rate is 60 percent of the daily rate of pay for
your lastjob in the base year, but not less than $12.70 a day or
more than 5 percent of the monthly compensation base.

Benefits on page 4);

a o b t a i n a n application f o r sickness b e n e f i t s f r o m
your employer, labor organization, o r RRB office;

For example, the monthly compensation base for 2004 is
$1,130.00, which results in a maximum daily benefit rate of
$56.00 for periods beginning after June 30, 2005. That rate
increases to $57.00 for periods beginning after June 30,2006.
The maximum benefit rate is subject t o increases under
indexing rules reflecting the growth in average national
wages. Contact your local RRB field office i f you need information about the maximum benefits rates for other periods.

a have your doctor complete the statement of sickness
in support of your claim for sickness benefits; and

a complete and f i l e the application for sickness benefits
w i t h i n 10 days of the first day y o u become sick o r
injured. You m a y lose benefits i f y o u file late. An
application is considered filed o n the day it is received
b y any office of the RRB.

Your daily rate o f pay is your straight-time rate of pay
including any cost-of-living allowances, but not including
overtime or other extra pay.
For mileage employees i n train and engine service, the
straight-time rate is the rate of pay for the number of
miles in a basic workday, depending o n occupation and
class of service. Earnings for miles run over the number
of miles in a basic workday d o not count.

Number of Days of Sickness
After y o u have satisfied the benefit year waiting period
requirement, benefits are generally p a i d f o r days o f
sickness over 4 in 14-day claim periods.

Tier I Tax Deductions
Except for benefits paid foron-the-job injuries, sickness
benefits are subject t o Tier I railroad retirement taxes i f
paid within 6 months after the month i n which y o u last
worked. Tier I tax deductions reduce the amount of benefits payable for a claim.

Medical Statements
T o receive sickness benefits, y o u must have your doctor
complete a statement o f sickness in support o f y o u r
claim. In addition, y o u may be asked t o have your doct o r p r o v i d e the RRB w i t h a d d i t i o n a l (supplemental)
medical information in order t o continue to receive your
sickness benefit payments. H o w often supplemental
medical information is required depends o n several factors, including when y o u are expected t o return t o work.
I n determining when y o u may return t o work, w e consider y o u r diagnosis, medical condition, age, normal
occupation and the estimated disability period previously
provided t o the RRB b y your doctor.

A statement of sickness may be completed by:
a licensed medical doctor trained in medical and
surgical diagnosis;
a licensed dentist in cases of infirmity relating t o the
teeth and gums;

Eligibility Requirements

a a licensed podiatrist if the infirmity relates t o the feet;
To receive sickness benefits y o u must:

a

b e unable t o w o r k due to sickness, injury, pregnancy,
or the birth of a child;

a a licensed chiropractor;
a a licensed doctor of clinical psychology;

a
a receive n o wages, salary, pay f o r time lost, vacation

a certified n u r s d m i d w i f e i n cases o f pregnancy, miscarriage, or childbirth;

pay, holiday pay, military reservist pay, pay under a
a superintendent o r other supervisory official o f a
hospital, clinic, or similar organization;

wage continuation plan, sick pay or other remunerat i o n f r o m railroad o r nonrailroad employment for the
days you claim benefits. You must report such pay o n
y o u r claim. However, payments u n d e r y o u r o w n
health or accident insurance policy, or group insurance
policy, o r under a supplemental sickness benefit plan
administered b y your employer or an insurance company d o not prevent the payment of sickness benefits
and should not be reported on your claim forms (see

a

a Christian Science practitioner;
a Physician Assistant
a nurse practitioner.

- Certified; o r

Sick Pay and
Supplemental Sickness Benefits
Sickness benefits are not payable for any day for which
y o u receive sick pay f r o m your employer. But benefits
may be paid if y o u receive supplemental sickness benefits
from your employer or an insurance company. Sick pay is
a continuation of part or all of your wages while y o u are
unable to work. Sick pay is generally subject t o all regular
payroll deductions. You must report sick pay o n y o u r
claim form; failure t o d o so may result in an overpayment
of RRB sickness benefits that y o u w i l l have to refund.
Supplemental sickness benefits are different f r o m sick
pay. Supplemental sickness benefits are payments made
b y your employer o r an insurance company t o supplement y o u r RRB benefits a n d are not subject t o Tier I I
retirement tax. Supplemental benefits are p a i d under
plans submitted b y your employer and approved b y the
RRB. D o not report supplemental sickness benefits o n
y o u r claim. If y o u d o not k n o w whether payments y o u
are receiving are supplemental under an RRB-approved
plan, contact the RRB office nearest y o u for assistance.

Medical Examination
In certain situations y o u may be required t o be examined
b y a doctor selected b y the RRB. I f y o u fail t o take the
medical examination when required, y o u may be disqualified from receiving sickness benefits.

Benefit Reductions
Benefits are not payable t o y o u in the full amount i f y o u
are also receiving:

a social security benefits,
a

a pension, annuity, or other retirement pay under a
Federal, State, or local law (such as a railroad retirement annuity, military retirement pay, a policeman's
or fireman's pension, etc.),

a

certain workers' compensation payments, or
any other social insurance payment under any law.

If y o u meet the other eligibility requirements, y o u may
receive benefits only in the amount b y which your sickness benefits exceed the other payments.

Disqualifications
Separation Allowance (severance pay, buyout)
If y o u have been p a i d a separation allowance b y y o u r
employer, y o u c a n n o t receive sickness benefits f o r
approximately the period o f time it w o u l d have taken
y o u t o earn the amount o f the allowance.

Be sure t o report all such other payments o n each claim
y o u file. I f y o u d o not, y o u m a y later be required t o
refund benefits. If the other payments are awarded after
y o u claim sickness benefits, but cover some or all of the
same days, contact the RRB immediately about repayment o f the benefits y o u received.

If y o u are a w a r d e d a n a n n u i t y u n d e r t h e R a i l r o a d

False or Fraudulent Claim
You w i l l be disqualified for both unemployment and sickness benefits for 75 days if y o u make a false or fraudulent
statement or claim in order to receive benefits. You may
also be subject to fine or imprisonment. The RRB conducts
checks, including computer matching checks, w i t h State
and Federal agencies as well as railroads, in order t o detect
fraudulent benefit claims.

Beneffis Under Other Laws
You w i l l be disqualified from receiving railroad sickness
insurance benefits for any day for which you:

a

receive sickness benefits under any other law; or
receive unemployment benefits under the Railroad
Unemployment Insurance Act or any similar law.

Retirement Act that is for days y o u were already paid
sickness benefits, y o u w i l l have to refund some or all of
your benefits. Generally, the amount y o u must repay is
w i t h h e l d f r o m y o u r accrued a n n u i t y . Y o u r a n n u i t y
award letter or notice o f annuity adjustment w i l l show
the amount of any sickness benefits withheld. Verify the
amount b y comparing it to the amount o f sickness benefits y o u received for the same period. Contact your local
RRB office immediately if y o u believe the amount withheld is incorrect. You w i l l be required t o refund benefits
t o the RRB i f the full amount was not withheld from your
accrued annuity.

Personal Injuly Settlements
You may receive benefits for any k i n d of injury or illness
whether it occurs o n or off the job; but if y o u are paid a
settlement or collect damages as a result o f the injury or
illness, the amount o f your benefits must be refunded t o

the RRB. This is true regardless o f a State's "no-fault" law.
The RRB w i l l normally notify the liable party, and the
person or company making the settlement or paying the
damages usually reimburses the RRB for the amount due.
However, if the RRB is not reimbursed in full at the time
o f settlement, y o u may have to repay benefits to the RRB.
Verify the accuracy o f the amount o f benefits withheld
f r o m your settlement b y checking your o w n record of
RRB payments or b y contacting the RRB. Notify the RRB
immediately if y o u believe the correct amount was not
withheld from your settlement.

Reconsideration and Waiver
Employee Rights
Reconsideration - If y o u d o n o t agree with any decision
denying y o u benefits or with an overpayment decision,
y o u may request reconsideration. Your request must be
in w r i t i n g a n d s h o u l d explain w h y y o u disagree. I f
y o u request reconsideration, y o u r request m u s t be
received at an office o f the RRB within 60 days o f the
date o f the letter notifying y o u of the adverse decision.
Be sure t o s i g n y o u r n a m e a n d include y o u r social
security number o n y o u r request.
Waiver

-

You may file Form W-4s, Voluntary Tax Withholding, with the
nearest RRB office if you want the RRB to withhold Federal
income tax from your benefits. To change or end withholding
you must file,another Form W-4s with the RRB. Form W-4s is
available upon request from the Internal Revenue Service.
The Railroad Unemployment lnsurance A c t specifically
exempts railroad sickness benefits from State income taxes.

Instructions for Completing Forms

1. The amount o f t h e overpayment is more than 10
times the current maximum daily benefit rate;

3.

Sickness benefits paid under the Railroad Unemployment
lnsurance Act, with the exception of sickness benefits paid
for an on-duty injury, are considered income for Federal
income tax purposes. Each year, the RRB sends railroad
employees Form W-2, Wage and Tax Statement, showing
the amount of sickness benefits paid during the preceding
calendar year. The amount shown o n Form W-2 is the
amount of benefits payable before deduction o f Tier I railroad retirement tax. The amount includes benefits payable
but withheld t o offset a debt to the RRB. A Form W-2 is not
issued if all benefits paid to an employee were for an on-thejob injury. A Form W-2 is also not issued if all benefits paid
to an employee in a tax year are repaid in the same year.

You may request waiver o f recovery o f your

overpayment o n l y if ALL o f t h e following conditions
are met:

2.

When Sickness Benefns are Taxable

y o u were not at fault in causing the overpayment;
and
recovery w o u l d cause y o u financial hardship t o the
extent t h a t y o u w o u l d n o t be able t o meet y o u r
ordinary and necessary living expenses or recovery
w o u l d be unfair for some other reason.

If your request for waiver is received at an office o f the
RRB w i t h i n 60 days from the date o f the letter notifying
y o u o f your debt, w e w i l l not recover the overpayment
until a decision is made o n your request.

Employer Rights
The Railroad Unemployment lnsurance Act requires the
RRB t o notify your base year employer(s) each time y o u
file a claim f o r benefits, a n d t o give the employer an
opportunity to submit information relevant to your claim
before t h e RRB makes a n initial determination o n the
claim. The RRB must also notify your employer each time
benefits are paid t o you. Your employer may appeal the
decision t o pay benefits. The appeal does not prevent the
t i m e l y p a y m e n t o f benefits. H o w e v e r , y o u m a y be
required t o repay benefits if the appeal is successful.

General Instructions
C o m p l e t e a l l items b y p r i n t i n g n e a t l y in i n k o r b y
u s i n g a t y p e w r i t e r . D o n o t s k i p a n y i t e m s unless
directed t o d o so. If y o u need more space t o answer a
question, enclose a separate sheet o f paper. Be sure t o
s i g n y o u r n a m e a n d date t h e f o r m b e f o r e m a i l i n g .
H a v e y o u r doctor complete Form SI-lb, Statement of
Sickness. D o n o t separate the forms.
Read the f o l l o w i n g instructions carefully before comp l e t i n g y o u r application. I f your application is not completed correctly, your benefits may be delayed. Contact
your local RRB office if y o u have questions o r need assistance in completing the form.

Important Information
The completed and signed form must be received b y an RRB
office within 10 days of the first day for which you want to
claim benefits. You may lose benefits if your application is
filed late. If the form is late, enclose an explanation.
Once your application has been processed, a claim form
will be mailed t o y o u for completion. You must complete
a n d return the claim t o the RRB office whose address
appears o n the claim. A notice of the claim w i l l be sent t o
your employer. A claim for the next 14-day period w i l l
be mailed t o y o u o n or about the last day o f the period
covered b y the claim.

Application for Sickness Benefits

I f more than one other vehicle was involved, give information for all vehicles o n a separate sheet o f paper.

(Form SI-I a)

-

SECTION A Identifying lnformation
Items 1 - 6 are self-explanatory.

-

SECllON B Infirmity and Employment lnformation
I t e m 7 is self-explanatory.
Item8

- Print the date you last worked for your last railroad

employer before the date you want your claim for sickness
benefits to begin. If you have already recovered from your
infirmity and have returned t o work, enter the date y o u
returned to work in ltem 19 on the reverse side of the form.

-

Insurance C o m p a n y Enter the complete name a n d
address of the insurance company of the owner of the
other vehicle involved in the accident.

-

Policy Information Enter the policy number of the insurance
policy held b y the owner of the other vehicle and the claim
number assigned by the insurancecompany, if you know it.

-

SECTION D Claim for Sickness Benefns lnformation
Your first sickness benefit claim is Items 16 through 20 o n
your Application for Sickness Benefits. After your application and claim have been received and processed, your
next sickness claim w i l l be mailed t o you.

Items 9 a n d 10 are self-explanatory.

-

I t e m 11 Print the title o f your job. For example, "Road
Brakeman."

-

I t e m 12 Print the department o f the railroad in which
y o u work. For example, "Train and Engine Service."

-

I t e m 13 A-C Complete this item if y o u worked for a nonrailroad employer or were self-employed after the last day
y o u worked for a railroad employer.
I t e m 13A - Print the name o f the company for which
y o u w o r k e d most recently. For example, "Acme
Accounting."
I t e m 13B - Print the t i t l e o f y o u r job. For example,
"Accountant."
I t e m 13C

- Print the date y o u last worked outside

the r a i l r o a d i n d u s t r y b e f o r e t h e date y o u w a n t
y o u r f i r s t sickness c l a i m t o begin. I f y o u h a v e
already recovered f r o m y o u r i n f i r m i t y a n d have
returned t o work, enter t h e date y o u returned t o
w o r k in ltem 19 o n the reverse side of the form.

-

SEC'CION C Accident and Insurance lnformation
Items 14 a n d 15A are self-explanatory.

-

I t e m 15B Print the location where your injury or illness
occurred. For example, "Hwy 51/County Rd 12, Toledo, Ohio."
Iteml 5 C
accident.

- Check "Yes" i f y o u were injured in a vehicular
-

I t e m l 5 D Complete the following about all the vehicles
involved in the accident other than your own.

-

O w n e r o f Car Enter the complete name and address of
the owner o f the other vehicle involved in the accident.

-

D r i v e r Enter the complete name and address o f the
driver of the other car or vehicle involved in the accident.

6

I t e m 16 is self-explanatory.

-

I t e m 17 Check "Yes" i f y o u want t o claim every d a y
from the date y o u entered in ltem 16 through the current
date as a day of sickness. Check "No" i f y o u d o not wish
t o claim every day. Remember that y o u cannot claim
benefits for any day o n which y o u worked or otherwise
earned wages, h o l i d a y pay, vacation pay, sick p a y
(excluding supplemental sickness benefits) or other pay.
This includes pay from full-time and part-time w o r k in
either railroad o r nonrailroad employment, a n d f r o m
self-employment. You may claim rest days o n which y o u
were sick or injured and for w h i c h y o u d o n o t receive
pay f r o m your employer.

-

I t e m 18 I f y o u checked "No" in ltem 17, enter the dates
that y o u d o not wish to claim.

-

I t e m 19 If y o u have recovered from your infirmity and
have returned to work, enter the date here. However, i f
y o u worked one or more days, b u t then continued t o be
unable t o w o r k , d o n o t enter a date in this item. For
example, i f y o u attempted t o return t o w o r k but found
that y o u were not able t o continue working, indicate the
days y o u worked and received wages in ltem 18, b u t d o
not enter a date in ltem 19.

-

I t e m 20A-C Y o u must complete a l l boxes to indicate
the type o f payments, i f any, that y o u have received or
w i l l receive for days i n the claim period. Put a check next
to each type o f payment that y o u have received or w i l l
receive and furnish the dates and/or other information
requested about the payment. The types o f payments are
explained below.

A. Wages - Wages are payments that y o u receive from
your railroad employer, f r o m a nonrailroad employer
o r y o u r o w n business f o r services y o u performed.
Benefits are not payable for any day for which y o u
receive wages.

-

R a i l r o a d Retirement A c t is n o t t h e same as
RRB sickness benefits.

Regular Pay Pay for t i m e worked, including
full-time and part-time work.
Vacation Pay - Payment for scheduled o r
assigned vacation days. Vacation pay does not
include "pay in lieu o f vacation." If y o u don't
k n o w if the payment y o u received was "pay i n
lieu of vacation," check w i t h your payroll office
before completing this item.

M i l i t a r y Retirement Pay - A n annuity, pension
or retainer p a y p a i d t o y o u b y the Federal
Government based o n your military service.

-

Worker's Compensation Disability payments
made t o y o u under a state law when y o u have
been injured o n t h e job.

H o l i d a y Pay - Payment from your employer for
a holiday.
M i l i t a r y Reservist Pay - Wages paid t o y o u b y
the Federal Government based o n your military
service.
Wage Continuation Pay - Salary or wages paid
b y your railroad employer when you have been
injured on-duty. The purpose of the payments is to
continue your wage or salary, not to supplement
RRB benefits. The payments are subject to normal
payroll deductions.
Earnings f r o m Self-Employment
services performed.

- Payment for

Sick Pay f r o m Your Employer - A continuation
o f a l l o r p a r t o f y o u r wages w h i l e y o u are
unable t o work. The t e r m "Sick Pay" does n o t
include supplemental sickness benefits. For an
explanation o f supplemental sickness benefits,
see page 4.
B. G o v e r n m e n t a l P a y m e n t s - Governmental payments are annuities o r other payments made to y o u
b y a county, city, state or Federal Government. I f y o u
are receiving a governmental payment, check the
appropriate box a n d g i v e the beginning date, the
gross amount and the frequency of the payment. For
an explanation of h o w governmental payments affect
the payment o f sickness benefits b y the RRB, see the
section Benefit Reductions o n page 4 .
Sickness o r U n e m p l o y m e n t B e n e f i t s U n d e r

-

A n y Other Law
Benefits p a i d t o y o u o n
account of sickness or unemployment b y a county, c i t y o r state g o v e r n m e n t , o r b y a n o t h e r
Federal agency.
Social Security Benefits - Benefits paid t o y o u
b y the Social Security Administration, excluding
supplemental security income payments (SSI).
Railroad Retirement o r Disability A n n u i t y M o n t h l y payments m a d e t o y o u b y t h e RRB
based o n y o u r age a n d r a i l r o a d service o r o n
d i s a b i l i t y . A n RRB a n n u i t y u n d e r t h e

Retirement Payments Under Another L a w - A n
annuity or pension paid t o y o u b y a county, city,
state or Federal Government.
C. O t h e r Payments - If you are receiving some type of
other payment, check the appropriate box and give the
date of the payment and who made the payment to you.
Settlement o r Damages f o r Personal Injury - A
payment received as a result of a judgment or the
settlement o f a personal-injury c l a i m against
your railroad employer or another party that y o u
held liable for your injury or illness.
Advances - A payment received in anticipation
of a settlement of a personal injury claim against
your railroad employer.
Separation Allowance (Buyout, Severance Pay) A payment received when you resign i n return
for a specified sum of money. The payments are
also referred t o as "buyouts" or "severance pay."
Payment may be made in a l u m p sum or installments in return for your resignation.
I t e m 21 is self-explanatory.

-

SECTION E Direct Deposit Information
I t e m 22

- Federal l a w requires that most Federal pay-

ments b e made by Direct Deposit. W i t h Direct Deposit,
y o u r benefit payments are sent directly t o y o u r bank,
savings and loan, credit union or other financial institution. Payments are sent electronically, w h i c h saves
money b y eliminating the need t o print and mail checks.
Direct Deposit has m a n y advantages. Direct Deposit
payments are generally available 2 t o 5 days sooner than
payment b y check. You d o n o t have t o w o r r y about a
check being lost, stolen o r misplaced, and y o u can be
away from home w i t h o u t the w o r r y o f a check sitting
unprotected in your mailbox. There is n o need t o w a i t
for mail delivery o f a check or t o make a special t r i p t o
your bank.
T o provide the information w e need t o correctly deposit
y o u r benefit payments, attach a voided personal check
t o y o u r application. I f y o u d o not attach a voided personal check, call your financial institution for the information y o u need to complete this item.

If y o u change your bank or your account while claiming
benefits, be sure t o submit a new voided personal check
t o the RRB t o establish Direct D e p o s i t t o y o u r n e w
account. D o not close your o l d account until y o u receive
the first RRB payment in your n e w account.
There are some exceptions that a l l o w payments t o be
made b y check:
If receiving your payments b y Direct Deposit would
cause y o u a hardship because y o u have a physical or
mental disability or because of a geographic, language,
or literacy barrier; o r
if y o u d o not have a checking or savings account at a
bank or other financial institution; or

if receiving your payments electronically would cause
y o u a financial hardship because it w o u l d cost y o u
more than receiving your payments b y check.

If any o f these apply t o you, check the box i n ltem 22F.

-

SECllON F Certification and Signature
I t e m 23 - By signing and dating this item y o u certify that
the information contained o n the f o r m is true, correct,
and complete.

If the sick or injured employee is unable t o sign in ltem 23,
the person completing the application should sign i n
ltem 23, and complete Form 9-10, Statement of Authority
to Act for Employee.

Statement of Authority to Act for
Employee (Form SI-I0 )
Completion o f Form 51-10, Statement of Authority to A c t
for Employee, is n o t required for an employee w h o can
sign papers o r can sign b y a m a r k a n d w h o understands transactions related t o his or her application for
benefits.

Section 1

- Statement of Individual Acting for

Employee
This section is t o be completed b y the individual w h o
signed the Application for Sickness Benefits and w h o w i l l
act o n behalf o f the employee. If y o u are not related to the
employee b y blood o r marriage, state your relationship
and explain w h y no relative is acting for the employee.
For example, an employee's foreman might explain: "My
relationship t o the employee is his foreman. H e has n o
immediate family."

Section 2

- Statement of Employee's Doctor

H a v e t h e employee's medical doctor complete t h i s
section.

Claim for Sickness Benefits
(Form SI-3)
T h e f o l l o w i n g instructions are f o r c l a i m forms m a i l e d

Statement of Sickness (Form SI-I b)
The Statement of Sickness must be completed b y your doct o r o r other qualified medical provider (see the section
M e d i c a l Statements o n page 3). If possible, have your
doctor complete the statement while y o u are at his or her
office, rather than leaving the f o r m for completion. I f y o u
must leave the f o r m f o r completion, explain t o y o u r
d o c t o r t h a t t h e f o r m is needed in o r d e r f o r y o u t o
receive bi-weekly benefit payments and that the f o r m
m u s t be received b y the Railroad Retirement Board
w i t h i n 10 days o f t h e f i r s t d a y y o u became sick o r
injured or y o u may lose benefits.
D o n o t separate t h e Statement of Sickness f r o m y o u r
Application for Sickness Benefits.

to y o u by the RRB. Read the instructions carefully before
completing y o u r claim forms. Failure t o complete your
claim correctly could delay the payment o f benefits.
IMPORTANTINFORMATION
Claims for days after your first claim (which is included
o n the Application for Sickness Benefits) w i l l be mailed t o
y o u for as long as y o u remain unable t o w o r k and eligible
for benefits. Y o u must complete and return each claim
promptly or y o u may lose benefits. The time for filing a
claim, including time for mailing, is limited to 30 days
from the last day o f the claim period, or 30 days from the
date the claim form was mailed to you, whichever is later.
If y o u r e t u r n t o w o r k and stop claiming benefits, b u t
become sick or injured again later in a benefit year, you
must file a new Application for Sickness Benefits.

RAILROAD REIIREMENT BOARD

FORM APPROVED OMB 3220-0039

CWM FOR SICKNESS BENEFITS

0 9 0 112805 112905

120205

J SMITH

02 02 700

123-45-6789

1. This claim is for sickness benefits for the period shown below. To claim benefits, mark the box under each date with the
appropriate code (X, E, P, or 0).

X - Claimed day of sickness
(Including rest days)
E - Day employed (Include railroad, nonrailroad, or self-employment)

This claim is for
11-21-05 through 12-04-05

P - Vacation, holiday, sick pay, or other pay from your employer
al
benefits)
(Do not r e ~ o rst u, ~, ~ l e m e n tsickness

0 - Day not claimed, other reason
21

22
I

23
I

24
I

25
I

26
I

27
I

28
I

29
I

1

30
I

I

2
I

3
I

4
I

I t e m 1- This item shows the days i n the claim period.
Below each day of the claim period, y o u must enter the
correct letter code showing whether y o u want t o claim
benefits for the day, or whether y o u worked, received
vacation pay, h o l i d a y pay, o r o t h e r p a y f r o m y o u r
employer, o r d o n o t w a n t t o claim benefits f o r some
other reason.

P - Enter a "P" f o r a n y d a y t h a t y o u w e r e n o t
employed, but w i l l receive payment from a railroad
o r nonrailroad employer. This includes such payments as vacation pay, holiday pay, wage continuation pay, sick pay (excluding supplemental sickness
benefits), daily wage guarantee payments, and pay
for time lost.

Remember that y o u cannot claim benefits for any day o n
which y o u worked o r otherwise earned regular wages,
vacation pay, holiday pay, military reservist pay, wage
continuation pay, sick pay (excluding supplemental sickness benefits), o r other pay. This includes pay from fullt i m e and part-time w o r k i n either railroad o r nonrailroad employment.

D o n o t enter "P" f o r days y o u receive payments
under a supplemental sickness benefit plan paid for
or financed b y your employer, such as benefits paid
b y Trustmark lnsurance Company or Provident Life
lnsurance Company. Such payments are normally
paid in addition t o your sickness benefits from the
RRB. For an explanation o f the difference between
regular sick pay, which you must report, and supplemental sickness benefits, see the back o f your claim
f o r m o r t h e section S i c k Pay a n d S u p p l e m e n t a l

Use the following letter codes t o show whether y o u are
claiming benefits for the days in the claim period.

X

- Enter an "X"

if you did not w o r k o n the day, w i l l
not receive any type o f p a y f o r t h e day, and were
unable t o w o r k because of injury or illness o n the day.
Any day you mark w i t h an "X" is considered t o be a
day of sickness for which y o u are claiming benefits.

Use an "X" t o claim normal rest days o n which y o u
were unable t o work. D o not claim your rest days i f
y o u were able t o work, worked, o r otherwise
received pay from either a railroad o r nonrailroad
employer for the days.

E - Enter an "E" if y o u were employed either f u l l
time or part time o n the day. Include w o r k for
either a railroad o r nonrailroad employer, and any
self-employment.

Sickness Benefits o n page 4 o f this booklet.

0 - Enter an "0" for days o n which you did not w o r k
and d i d not receive any type of payment, but which
y o u d o not wish t o claim for some other reason.
A n example of how the boxes are to be completed is shown
above.
I t e m 2 - I f y o u have recovered from your infirmity and
have returned t o work, check the "YES" box and enter
the date here. I f y o u attempted t o return t o w o r k b u t
found that y o u were not able t o continue working, check
t h e "NO" box a n d indicate, i n Item 1, t h e days y o u
worked and received wages, but d o not enter a return-tow o r k date in this item.

-

Item 3 T h i s i t e m i s p r e - f i l l e d with t h e n a m e a n d
address o f a n RRB office. M a i l y o u r completed claim t o
t h a t office.

5. A private collection agency, the General Accounting
Office, the Department o f Justice, o r the Internal Revenue
Service for the collection o f an overpayment.

Item 4 - T h i s i t e m i s p r e - f i l l e d with y o u r n a m e a n d
address. If necessary, show corrections t o y o u r name and

6. Employers o r insurance companies f o r use in administering supplemental benefit o r health insurance plans.

address in the box.

Item 5

-

See I t e m 20 o n p a g e 6 o f t h i s b o o k l e t f o r
instructions o n completing this item.

-

Item 6 B y signing a n d dating this item y o u certify that
t h e information contained o n y o u r claim f o r m is true a n d
complete. D o n o t complete a n d sign the c l a i m f o r m
before the last d a y o f t h e claim period. If y o u r claim is
received b y the RRB before the last d a y o f the claim period, benefits d u e y o u m a y be delayed o r denied.

7. L a w enforcement agencies a n d t h e D e p a r t m e n t o f
Justice for investigating o r prosecuting a violation o f law.

8. Employers t o v e r i f y entitlement t o benefits a n d t o
p r o v i d e notice o f benefit p a y m e n t determinations.

9. State unemployment agencies t o verify entitlement t o
benefits.
O t h e r t h a n i n f o r m a t i o n t h a t m a y be disclosed routinely, n o i n f o r m a t i o n a b o u t y o u r c l a i m m a y b e disclosed
w i t h o u t y o u r consent.

Privacy Act Notice
Computer Matching and Privacy
T o receive sickness benefits y o u m u s t a p p l y f o r t h e m
a n d furnish information. lnformation that t h e RRB asks
y o u t o furnish is used t o determine if y o u are eligible for
b e n e f i t s a n d t h e a m o u n t o f benefits p a y a b l e t o y o u .
A l t h o u g h furnishing information, including y o u r social
security number, is voluntary, t h e RRB cannot p a y y o u
benefits w i t h o u t t h i s information. T h e RRB's a u t h o r i t y
f o r requesting information is Section 5(b) o f the Railroad
Unemployment Insurance Act.
T h e RRB may routinely furnish information f r o m its
records t o other government agencies a n d t o other persons o r companies (see l i s t below) f o r t h e p u r p o s e o f
a d m i n i s t e r i n g t h e Railroad U n e m p l o y m e n t Insurance
Act, t h e Social Security Act, o r other benefit programs
u n d e r Federal o r State laws.
The RRB may routinely furnish information t o the followi n g individuals, organizations, and/or agencies:

1. T h e U. S. Treasury Department a n d t h e U.S. Postal
Service, t o issue benefit payments a n d t o r e p o r t n o n delivery, forgery, theft o r loss o f a benefit payment.
2. A person o r company w h i c h the claimant reports m a y
a w a r d p a y for t i m e lost or some similar payment for the
same period for w h i c h the RRB pays benefits.

3. Persons o r companies named b y the claimant as liable
for p a y i n g damages for t h e same i n j u r y o r illness f o r
w h i c h t h e RRB pays sickness benefits.

4. The Internal Revenue Service f o r use in administering
Federal tax laws.

Protection Act Notice
In a d d i t i o n t o t h e uses o f i n f o r m a t i o n described in t h e
preceding Privacy A c t Notice, i n f o r m a t i o n y o u p r o v i d e
m a y b e used, w i t h o u t y o u r consent, in a u t o m a t e d
m a t c h i n g programs. These m a t c h i n g p r o g r a m s are a
c o m p u t e r c o m p a r i s o n o f R a i l r o a d Retirement B o a r d
records with records k e p t b y other Federal agencies o r
State a n d local g o v e r n m e n t a l agencies. I n f o r m a t i o n
f r o m these matching programs can be used t o establish
o r v e r i f y a person's e l i g i b i l i t y f o r benefits a n d f o r
repayment o f benefits o r delinquent debts.

What Are Computer Matching kograrns?
Computer matching programs compare o u r records with
those o f other Federal, State, o r local government agencies. All agencies m a y use matching programs t o find o r
prove that a person qualifies f o r benefits p a i d for b y the
Federal Government.

How Do Computer Matching Programs Affect
You?
O n forms that y o u fill o u t f o r u s y o u give u s facts about
yourself. Sometimes, w e check t h e facts y o u and others
give us. W e use computer matching t o d o t h e checking.
The l a w allows u s t o check this w a y even if y o u d o n o t
agree t o it. W e can also g i v e any facts w e have about y o u
t o other governmental agencies for t h e m t o use in their
computer matching programs.

Paperwork Reduction Act Notice
T o receive sickness benefits, y o u m u s t complete a n
application and claim form(s). You may also be asked t o
complete other forms. Some o f these forms are listed
below along w i t h estimates of h o w long w e t h i n k i t takes
t o complete them. The estimates include time for reviewing
t h e instructions, getting the needed information, a n d
reviewing the completed form. Federal agencies may not
conduct or sponsor, and respondents are not required t o
respond to, a collection of information unless it displays a
valid O M B number. If you wish, send comments regarding
the accuracy of our estimates or other aspect of the forms,
including suggestions for reducing completion time, t o the
Chief o f Information Resources Management, Railroad
Retirement Board, 844 N. Rush Street, Chicago Illinois
60611-2092. Be sure t o include the form title and control
number (in parentheses) w i t h your comments.

Form
No.

Estimated
Completion
Time
Title

(Minutes)

SI-la

Application f o r Sickness
Benefits (3220-0039)

10

SI-1b

Statement o f Sickness
(3220-0039)

8

SI-3

C l a i m f o r Sickness
Benefits (3220-0039)

5

SI-10

Statement o f A u t h o r i t y
t o A c t f o r Employee
(3220-0034)

6

ID-7h

Notice o f Non-Entitlement
t o Sickness Benefits a n d
Information o n
Unemployment Benefits
(3220-0039)

5

Nondiscrimination on the
Basis of Disability
Under Section 504 o f the Rehabilitation Act of 1973 and
RRB regulations, n o qualified person may be discriminated
against o n the basis of disability. The RRB's programs and
activities must be accessible t o all qualified applicants and
beneficiaries, including those w h o are vision or hearing
impaired. Disabled persons needing assistance (including
auxiliary aids or program information i n accessible formats)
should contact the nearest RRB office.
Complaints o f alleged discrimination b y the RRB o n the
basis of disability must be filed within 90 days in writing
with the Director o f Administration, Railroad Retirement
Board, 844 North Rush Street, Chicago, Illinois 60611-2092.
Questions about individual rights under this regulation
may be directed t o the RRB's Director of Equal Opportunity
at the same address.

RRB Helpline 1-800-808-0772
The RRB HelpLine is a n automated telephone service available 24 hours a day, 7 days a week. You can
call the RRB HelpLine toll-free f r o m either a touchtone o r rotary telephone t o get the f o l l o w i n g informat i o n about y o u r unemployment o r sickness benefits:
t h e a m o u n t a n d date o f y o u r latest benefit
payment, a n d the claim period for w h i c h the
payment was made;
i n f o r m a t i o n a b o u t y o u r last 5 b e n e f i t p a y ments; a n d
confirmation o f whether we've received y o u r
latest claim, application, o r supplemental doctor's statement.

W e u p d a t e t h e RRB H e l p L i n e once each
w e e k n i g h t with p a y m e n t i n f o r m a t i o n ; w e
u p d a t e i n f o r m a t i o n a b o u t applications,
c l a i m s , a n d s u p p l e m e n t a l d o c t o r ' s statements as w e receive t h e forms. Y o u will need
y o u r social s e c u r i t y n u m b e r a n d y o u r
Personal Identification N u m b e r (PIN) t o get
information about y o u r benefit payments
a n d claims. Your P I N is printed o n the back
o f each c l a i m f o r m w e m a i l t o y o u . Each
claim will also have a record o f y o u r last 3
payments. Use t h e record o f payments, t h e
RRB H e l p L i n e a n d t h e tables b e l o w t o keep
track o f y o u r claims a n d payments.

Record of Claims Submitted
Please a l l o w at least 15 days f r o m the date y o u
m a i l y o u r claim t o receive a payment. That t i m e is
needed f o r delivery o f y o u r claim a n d payment,
a n d t o a l l o w y o u r employer t o submit information
about y o u r claim.
Beginning Date
Number o f
o f Claim
Days Claimed

Date Mailed
t o RRB

Record of
Payments Received
Amount of
Payment

Date Payment
Received

Important Reminders
F i l i n g Requirements-To avoid losing sickness benefits, y o u r benefit application must be received b y a
Railroad Retirement Board (RRB) office within 10
days o f t h e first d a y f o r w h i c h y o u w a n t t o c l a i m
benefits. Your sickness claims must .be filed within 30
days o f the last d a y o f the claim o r 30 days f r o m the
date w e m a i l the f o r m t o you, whichever is later.
Benefit Yearpase Year- A n e w benefit year begins
each July 1. Eligibility for benefits in a benefit year is
based o n y o u r earnings in the previous calendar year
(base year). F o r a n e x a m p l e , see s e c t i o n t i t l e d
Qualification Requirements.
W a i t i n g P e r i o d Requirement-To satisfy a one-week
waiting period requirement, n o benefits are payable
for y o u r first 7 days o f sickness in y o u r first claim in a
p e r i o d o f c o n t i n u i n g sickness, unless y o u h a v e
already served a waiting period in the benefit year.

Even t h o u g h n o benefits are payable f o r t h e f i r s t 7
d a y s o f sickness, y o u m u s t f i l e a c l a i m f o r y o u r
days o f sickness d u r i n g t h e w a i t i n g period; otherw i s e y o u m a y lose b e n e f i t s f o r c l a i m s a f t e r t h e
w a i t i n g period.
D o N o t C l a i m Benefits f o r Days Y o u W o r k or
Receive Pay- Benefits are n o t payable for any d a y
for w h i c h y o u receive pay. This includes wages f r o m
military reservist duty, f u l l - o r part-time w o r k f o r a
railroad, n o n - r a i l r o a d employer, o r self-employment. It also includes vacation pay, holiday pay, p a y
f o r t i m e lost, g u a r a n t e e p a y a n d o t h e r t y p e s o f
remuneration.

-

Reconsideration R i g h t s Y o u m a y request reconsideration o f any decision denying y o u benefits. A
request f o r reconsideration m u s t be made in w r i t i n g
within 60 days o f the date o f notice o f the Railroad
Retirement Board's adverse decision.

Fraud and Abuse Hot Line
C a l l t h e t o l l - f r e e H o t L i n e if y o u h a v e reason t o
believe t h a t someone is receiving r a i l r o a d u n e m p l o y m e n t o r sickness benefits t o w h i c h h e o r she is
n o t entitled. The H o t L i n e has been installed b y t h e
Railroad Retirement Board's lnspector General t o
receive a n y evidence o f f r a u d o r abuse o f t h e RRB's
benefit programs.

The toll-free H o t L i n e number is 1-800-772-4258. Or
y o u m a y send y o u r complaints in w r i t i n g to: RRB,
O I G , H o t L i n e O f f i c e r , 844 N o r t h R u s h Street,
Chicago, Illinois 60611-2092. Please d o n o t call t h e
Inspector General's H o t L i n e with questions about
eligibility requirements, delayed claims, o r similar
problems. Such matters s h o u l d be directed t o t h e
nearest Railroad Retirement Board field office.

Did You Know. .
Railroad employees d o n o t p a y f o r t h e i r sickness
benefits protection. The funds come f r o m a payroll
tax o n employers.

.

A fine, j a i l sentence, a n d d i s q u a l i f i c a t i o n m a y be
imposed u p o n a n y person f o u n d t o have w i t h h e l d
information o r t o have made false o r fraudulent
statements o r c l a i m s f o r t h e p u r p o s e o f causing
benefits t o be paid.

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039

Application
for Sickness Benefits
..
Identifying Information
1.

Emnlovee's Name (First. Middle Initial. and I .act)

12. Social Securitv Number

4. Date of Birth

3. Employee's Street Address, City, State and ZIP Code
(Including Apartment Number)

5. Sex

Infirmity and Employment Information
7. Date You Became Sick or Injured

8. Date You Last Worked for a Railroad
9. Last Railroad Employer (Name of Company)
10. Location of Last Railroad Employment (CityIState)
11. Last Railroad Occupation
12. Department
13. If you worked for a nonrailroad employer after the date shown in Item 8, complete Items A, B, and C, below. Othetwise, go to Item 14.
A. Last Nomailroad Employer (Name of Company)
B. Last Occupation After Railroad Work
C. Date Last Worked After Railroad Work

-

@

Accident and Insurance Information

a

14. Are you applying for sickness benefits because you were injured at work or have a work-related illness?
Yes
15. Have you filed or do you expect to file a lawsuit or claim against any person or company for personal injury?
Yes - Complete Items A-D, below
No - Go to Item 16
A. Furnish the name and complete address of the person or company.

a

a No

a

Address
City, State, ZIP Code
B. Give the place where the injury occurred.
C. Were you injured in an automobile accident?

a Yes a NO- GOto Item 16

D. If you were injured in an automobile accident, provide information about all the vehicles, other than your own, that were
involved in the accident that caused your injury. Information about your vehicle and insurance company is not needed. If you
need more apace attach a separate sheet of paper.

Owner of Car other vehicle)
Name

Name

Address

Address

City, State, ZIP Code

1

City, s G e , ZIP Code

Insurance Company (other vehicle)

Policy Information (other vehicle)

Name

Policy Number
I

Address

Claim Number

City, State, ZIP Code
I

Continued on Next Page

SI- 1a (02-0

Claim for Sickness Benefits Information
6. Enter the earliest date you wish to claim sickness benefits.
7. Are you claiming all the days of sickness beginning with the date you entered in item 16? (Note: You may claim rest days if you
were unable to work and did not receive pay from your employer.)
Yes - Go to Item 19
No - Go to Item 18
8. Enter any dates that you do not wish to claim.
9. Enter the date you returned to work (if applicable).
0. You must complete all boxes to indicate if you have received or will receive any of the following payments for your days of sickness.
If you check "YES" for any item, be sure to provide the requested information.

a

a

A. WAGES (Include Railroad and Nonrailroad Wages)
YES NO If "YES," show the dates for which you were paid in MonthDayTYear format below.
Regular Wages.. ...............
Vacation Pay.. ................
Holiday Pay ..................
Military Reservist Pay ..........
Wage Continuation Pay .........
Earnings from Self-Employment . .
Sick Pay from Your Employer. ...
(but not payments supplementing Railroad Retirement Board (RRB) benefits. See Booklet UB-11)

a
a
a
a
a
a
a

B. GOVERNMENTAL PAYMENTS (Not RRB Sickness Benefits)
YES NO If "YES," enclose copy of award letter and complete Items 1 - 3 below.
Sickness or Unemployment Benefits Under Any Other Law
1. Beginning Date of Payment
Social Security Benefits
2. Gross Amount of Payment $
Railroad Retirement or Disability Annuity
3. How often do you receive the payment?
Military Retirement Pay
Weekly
Monthly
Yearly
Worker's Compensation
Other:
Retirement Payments Under Another Law

a
a a
a
a
a
a

a
a

-

a

a

-

C. OTHER PAYMENTS
YES NO If "YES," complete Items 1 and 2.
Settlement or Damages for Personal Injury
1. Date of Payment
Advances
2. Paid By:
Separation Allowance (Buyout, Severance Pay)
1. If the date you are submitting this form is more than 30 days after the date you entered in item 16, answer the following:
A. Why did it take more than 30 days to submit this form? If more space is needed, attach a separate sheet of paper.

a a

a
a

B. How did you obtain this form?
C. Who provided this form to you?
D. On what date did you obtain the form?
E. Furnish the name and title of any person from whom you asked for help in completing and filing the forms.
NAME
TITLE

Direct Deposit Information
2. Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To provide

the information we need to correctly deposit your payments, attach a voided personal check and go to Item 23, or call your
financial institution for the information you need to complete Items A-E. If you do not have a bank account, or receiving your payments by Direct Deposit would cause you a hardship, go to Item P.
A. Routing Transit Number
C. Account Type:

B. Account No.
D. Name of Financial Institution:

a Checking a Saving
E. Telephone No. (Include Area Code) (
)
F. a Check this box if you do not have a checking, or savings account, or if Direct Deposit would cause you a hardship.
Certification and Signature
3. I waive any "doctor-patient privilege" I may have with respect to the disclosure of information concerning the period of sickness or injury on
which my claim is based. I certifLthat I understand and agree to the requirements in Booklet UB-11. I know that disqualification and civil and

criminal penalties may be imposed on me for false or h d u l e n t statements or claims or for withholding information to get benefits fiom the

RRB.I a E i that the informationgiven on this form is true, correct and complete. NOTE: If the sick or injured employee is unable to sign
this form, sign your name above and complete Section 1 of the attached Form SI-10, Statement of Authority to Act for Employee.
SIGNATURE.
SI-la (02-01)

DATE
HAVE YOUR DOCTOR COMPLETE THE ATTACHED STATEMENT OF SICKNESS

United States of America
Railroad Retirement Board

Form Approved

OMB No. 3220-0039

Statement of Sickness
/~Sfrll~fi~n
This
S :form is to be executed by (I)a doctor trained in medical, surgical, dental or psychological

diagnosis of
the infirmity described, (2) a certified nurse/midwife in cases of pregnancy or childbirth, (3) a supervisory official of a
hospital or similar institution, (4) a chiropractor, (5) a Physician Assistant Certified, or (6) a nurse practitioner. This form
should be completed and returned to the patient immediately for prompt mailing; otherwise he/she may lose benefits.
Supplementary medical information may be attached or furnished directly to the Railroad Retirement Board (RRB) at the
address shown below. If such information is furnished, please include the patient's social security number and name on the
report Please complete section 2 on the reverse side if patient is incapable of signing forms.

-

1. Patient's Name (First, Middle, and Last)

2. Patient's Social Security Number

3, Have you examined or treated the patient for his or her injury or illness?

Yes

1
I

a. Date patient became sick or injured

m No - Go to ltem 9

b. List all dates of examination and treatment for this infirmity

c. Probable date of next examination
4. Diagnosis and concurrent conditions

5. Does the patient's condition require surgery?

Yes

m No -Go t o ltem 6

a. Date on which surgery was or will be performed

b. Surgical procedure that was or will be performed

6. Does the patient's condition require hospitalization?

m Yes - Give the period of hospital confinement: From
m No

To

7. If patient is not working because of maternity or childbirth, give:
a. Date patient became unable to work

,

b. Estimated or actual date of delivery

,

,

8. Give the date you believe the patient became or will become able to resume work in his or her occupation.
(If indefinite or unknown, please give an estimated date.)

9. 1 certify that the information I am giving is true, complete, and correct. I understand that criminal and civil penalties may be imposed
on me for false or fraudulent statements or for withholding information to cause or prevent payment of benefits by the RRB.

Address

Office Telephone Number (Include Area Code)

(

Date

1

Tax Identification Number

PAPERWORK REDUCTION ACT NOTICE TO DOCTOR

Medical evidence is needed to support the payment of claims for sickness benefits under the Railroad Unemployment Insurance Act (RUIA). The RRB is
authorized to collect this information under section 12(i) of the RUIA. You are not required to furnish this information. If you do not, however, no benefits
can be paid to your patient. We estimate this form and the form on the back of this page take an average of 8 and 6 minutes to complete, respectively.
The estimates include the time for reviewing the instructions, getting the needed data, and reviewing the completed forms. 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 aspect of this form, including suggestions for reducing completion time, to the Chief of
Information Resouces Management, Railroad Retirement Board, 844 N Rush Street, Chicago, Illinois, 60611-2092. Send completed forms to:
U.S. RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS-OPERATIONS
POST OFFICE BOX 10695
CHICAGO, ILLINOIS 60610-0695

Doctor: See Next Page

FORM SI-I b (02-01)

United States of America
Railroad Retirement Board

Form approved
OMB No. 3220-0034

Statement Of Authority To Act For Employee
It is not necessary to complete this form for an employee who can sign papers or can
sign by mark and understands transactions relating to his or her sickness benefits.

Instructions
1. Complete Section 1 and have the employee's medical doctor complete Section 2. If you are not related to the
employee by blood or marriage, state your relationship and why no relative is acting for him or her. For example,
an employee's union representative might explain: "I am his union chairman. He has no immediate family."
2. Complete t h i s statement by following t h e instructions i n the UB-11 booklet under "Instructions for
Completing Forms, Statement of Authority to Act for Employee (SI-lo)." Signing this statement gives you the
authority to sign any claim forms on behalf of the employee. When signing claim forms use your full name,
and beneath your signature, write "On behalf of" and the employee's full name.
3. Return this form with the next application or claim form you file with the RRB.

Statement of Individual Acting for Employee
It is my belief that

(Employee's Name)

(Social Security Number)

whose address is
(Employee's Address)

is a t this time incapable of signing forms i n connection with obtaining sickness benefits under the Railroad
Unemployment Insurance Act; of transacting the necessary business relative to his or her application and claims
for such benefits; and of applying the proceeds of any sickness benefit payments.

I believe the employee to be incapable because

(Briefly describe employee's condition)

My relationship to t h e employee is
I affirm that, i n the transaction of business relating to the application and claims of this employee, including
the use of any benefit payments, I will act on behalf of and in the best interest of the employee. I will promptly
notify the RRB a t such time a s this employee's condition changes so that I need no longer act for him or her. I
understand that criminal and civil penalties may be imposed on me for providing false, incomplete, or fraudulent
statements, or for withholding information to cause the payment of benefits. I certify that, to the best of my
knowledge, the information I have provided is true, complete, and correct.
Name (please print)

Phone Number

Signature

(

Street Address (please print)

1

State ZIP Code Date

City

Statement of Employee's Doctor
I have examined the employee named above and find that helshe is incapable of signing forms and transacting
business relative to hislher claims for sickness benefits under the Railroad Unemployment Insurance Act.
Name of Doctor (please print)
Office Street Address (please print)
Tax Identification Number

Signature of Doctor
City

State ZIP Code Date