SI-1A (proposed) Application for Sickness Benefits

United States of America
Railroad Retbment Board

Form Approved

OMB No.32204039

Application for Sickness Benefits
Identifying Information
1. Elmployee's Name (First, Middle Initial, and Last)

2. Social Securify Number

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

II

I

-

4. Date of Birth
Month
Day

I

II

I

-

II

II

II

5. Sex

Year

0 Male
0 Female

6.Telephone Number (Include Area Code)
I

'

Infirmity and Employment Information
(7. Date You Became Sick or Injured
18. Date You Last Worked for a Railroad
(9. Last Railroad Employer (Name of Company)
lo. Location of Last Railroad Employment (City/State)
11. Last R a i i d Occupation
12. Department
13. If you worked for a nonrailroad employer atter the date shown in Item 8, complete Items A, B, and C, below. Otherwise, go to Item 14.
A. Last Nonrailmsd Employer (Name of Company)
B. Last Occupation Afier Railroad Work
C. Date Last Worked After Railroad Work

1

1

II

I

Yes
14. Are you applying for sickness benefits because you were injured at work or have a work-related illness?
15. Have you filed or do you expect to file a lawsuit or claim against any person or company for personal injury?
0 Yes Complete ItemsA-D,below 0 No Go to Item 16
A. Furnish the name and complete address of the person or company.

-

I
I

0 No

-

I

Name
Address
City, State, ZIP Code

B. Give the place where the injury o c c d .

C. Were you injured in an automobile accident?

0 Yes

p No - Go to Item 16

D. If you were injured in an automobile accident, provide information about all the vehicles, other tlrmyour 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.
Name

I

Address

I

City, State, ZIP Code

Name
I

Name

I

I
I
I

Accident and Insurance Information

e

I

I

1

Address

I

City, state,SCode

I

Policy Number

City, state, ZIP
Code
Continued on Reverse Side

SI-la File Typeapplication/pdfFile Modified2007-03-13File Created2007-03-13