ID-11B (Proposed) Notice of Insufficient Medical and Late Filing

PROPOSED
Form Approved

OMB N O . 3220-0039

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS - OPERATIONS
P.O. BOX 10695
Chicago, IL 606 11-0695

In reply refer to
Name
SS No.:
REQ:
NOTICE OF INSUFFICIENT MEDICAL AND LATE FILING
We received your Application for Sickness Benefifs for your infirmity of
The Statement of Sickness which accompanied your application indicates that you were
, for this infirmity. Consequently, sickness benefits
first seen by your doctor on
cannot be paid for the days
through
,because there is no medical
evidence supporting your inability to work during that 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 yol.lr 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)

ID-11B (XX-XX)

UNITED STATES RAILROAD RETIREMENT BOARD

Form Approved
OMB NO. 3220-0039
SS No.
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 corr~pletethese forms and file them with the Railroad
Retirement Board? Provide the dates these steps were taken.

3.

Explain why your forms were filed late.

4.

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

5.

Do you wish to claim as days of sickness all days for which you may be entitled to benefits
prior to MM-DD-WYY?
YES - Go to item 7
NO

6.

Enter any days you do not wish to claim.

7.

Will you receive wages or other pay (other than these benefits) for your days of sickness?
YES - Go to Item 11
NO

8.

What kind of wages or other pay will you receive?

9.

List the exact days for which you will receive any such payments:

10. Who will make these payments?
11. CERTIFICATION: I know that disqualifications and civil and criminal penalties may be
irr~posedon 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 inforriation, failure to do so could result in a loss of benefits
to you. We estimate this form takes an average of 4 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
h
Chicago, IL 6061 1-2092.
Resources Management, Railroad Retirement Board, 844 N. ~ u s Street,
ID-11B (XX-XX)