SI-3 (07-04) Claim for Sickness Benefits

U.S. RAILROAD RETIREMENT BOARD

Telephone:
Hours:

INSTRUCTIONS
1. Print all responses neatly in ink.
2. Make sure your name and address are correct. If they are not, enter the correct information in ltem 4.
3.

Read carefully the section titled "Instructions for Completing Forms - Claim for Sickness Benefits (SI-3)" in the UB-I 1
booklet before completing the claim form on the next page.

4. At the end of the claim period shown, complete and mail the claim in the envelope provided. If you need assistance,
telephone the RRB office identified above.

5. Waitinq PeriodlBenefit Payments - If this is your first claim for your current illness or infirmity and you have not
previously satisfied the benefit year waiting period requirement, benefits will be paid to you for your days of sickness
over 7 in this period. Otherwise, benefits are normally payable for the number of days of sickness over 4 In each cla~m
period. Allow 15 calendar days from the date you mail your claim for a payment to be received. If you do not receive
a payment or other notice within 15 days, contact the RRB office identified above, for information about the status of
your claim.
6. Rest Davs - Use an " X in ltem 1 to claim benefits for rest days on which you were sick or injured and for which you do
not receive wages or other pay from your employer.

7. Sick Pav and Supplemental Sickness Benefits - Sickness benefits from the RRB are not payable for any day for
which you receive sick pay from your employer. Supplemental sickness benefits on the other hand, do not affect your
RRB sickness benefits. Sickpay is a continuation of part or all of your wages wh~leyou are unable to work. Sickpay
is generally subject to all regular payroll deductions. You must report your sick pay on your claim form; fallure to
do so may result in an overpayment of RRB sickness benefits that you will have to repay.
Supplemental sickness benefits are different from s~ckpay. Supplemental sickness benefits are payments made by
your employer to supplement your RRB benefits. Supplemental sickness benefits are not subject to Tier II tax.
Supplemental benefits are paid under plans submitted by employers and approved by the RRB. You should not
report supplemental sickness benefits on your claim. If you do not know whether payments you are receiving are
supplemental under an RRB-approved plan, contact the RRB office identified above for assistance.
IMPORTANT: Promptly return your claim form to the RRB after the last day of the claim period, or you may lose benefits.
Your claim must be received within 30 days from the last day of the claim period or 30 days from the date the form
was mailed t o you, whichever is later. If your claim is late because of circumstances beyond your control, enclose an
explanation.
RRB H e l ~ L i n e- For information about the benefits paid to you or to check on the status of your application or claim form,
call the RRB HelpLine at 1-800-808-0772.
DO NOT SIGN, DATE, OR MAIL THE CLAIM FORM BEFORE THE LAST DAY OF THlS CLAIM PERIOD.
(REFER
TO BOOKLET
UB-11 FOR PRIVACY
ACTAND PAPERWORK
REDUCTION
NOTICES
AND FURTHER INSTRUCTIONS ON COMPLETING THlS FORM)
COMPLETE AND KEEP FOR YOUR RECORDS
Claim Period:

through

Date Mailed to RRB:
FORM SI-3 (07-04)

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB 3220-0039

CLAlM FOR SICKNESS BENEFITS
011107
1.

01-01

9420

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

P - Vacation, holiday, sick pay, or other pay from your employer
(Do not report supplemental sickness benefits)
0 - Day not claimed, other reason

through
Mark each box with X, E, P, or 0
2.

3.

+

U

U

A. Have you returned to work?
Yes
No
B. If "Yes," enter the date you returned to work
MAKE SURE YOUR NAME AND ADDRESS ARE CORRECT
Return your claim to the address below
4. If your name or address is incorrect, print changes below
Railroad Retirement Board

5.

You must complete all boxes to indicate if you have received or w ~ lreceive
l
any of the following payments for your days of
sickness. If y o u check "YES" for any item, be sure t o provide the requested information.
A. WAGES (Include railroad and nonrailroad wages) - If "YES," show dates you were paid in MonthlDayNear format below.
YES NO
-

Regular Wages ................
.
..................................
Vacation Pay ........................................................
Holiday Pay ..........................................................
Military Reservist Pay ............................................
................
Wage Continuation Pay .................
.
.
Earnings from Self-Employment ............................
Sick Pay from Your Employer (but notpayments
supplementing RRB benefits, see Booklet UB-1 I)............

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

6.

1. Date of Payment
Settlement or Damages for Personal Injury
Advances
2. Paid by
Separation Allowance (Buyout, Severance Pay)
CERTIFICATION: I certify that I understand and agree to the requirements in Booklet LIB-11. I know 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 RRB. I affirm that the information given on this form is true, correct, and complete.
DO NOT SIGN, DATE, OR MAIL THIS CLAIM BEFORE THE LAST DAY OF THlS CLAIM PERIOD
Telephone No
Signature
Date
(

1

If employee is unable t o sign, enter name o f person who completed this form

FORM SI-3 (07-04)