SI-1c (proposed) Supplemental Information on Accident and Insurance

U.S. RAILROAD RETIREMENT BOARD
O f f i c e of Programs - O p e r a t i o n s
P. 0. Box 10695
Chicago, I l l i n o i s 60610-0695

REQUEST FOR INFORMATION ON ACCIDENT AND INSURANCE
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~ n f o r m a t i o nr e q u e s t e d on t h e back o f this letter i s needed i n c o n n e c t i o n
w i t h , your applica.tion
f of@h&f it$ ' f o r .y&u,r,ifi-jGry/illfiess of
06-18-g8. The R a i l r o a d Retirement B . F , r d s (RRB) a u t h o r i t y f o r r e q u e s t i n g
t h i s information i s s e e t i a n 5(b) m d ' . ~ 2 4 ! o )o* t h e ~ a i i r a ; a d- ~ n e m ~ ~ o ~ & e . n t
Ihsurance A c t (RUIA)
Because you a r e ' r e q u i r e d t o provi'de t h i s
information under s&&ion'9 (a) of the . ~ t f r A , fai1u.r- eci - dompleee and r e t u r n
t h i s form c o u l d r e s u l t i n a f i n e o r imprisonment o r both.
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Paper,~or~~'.~&&t-On A c t Netice: W& ;:e%$sfiate
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t h a t t h f s farm t a k e s
average of 5 minutes t o complete, i n c l u d i n g t h e t i m e f o r r e v i & L + h i g t h e i n & t r u c t i o n s , g e t t i n g t h e needed data ;arid i e v i e w i n g the'e b m p ~ e t e df o m . .

F e d e r a l a g e n c i e s may n o t cuilduct o r sponsor, a n d r e s p o n d e n t s are riat
r e q u i r e d t o respond t o a c o i l e c t i o n o f i n f o r m a t t o n u n l e s s it d i h f i l a y s a
v a l i d OKB number. If you wish., sehd & e n t s
r e g a r d i n g t h e accuracy of o r
Our e s t i m a t e o r any- o t h e r aspectA of t h i s form, i n c l u d i n g ~ u g g e s t i o n sf o r
reducing. c o m p l e t i o n t i m e , t o t h e C h i e f of I n f o r m a t i o n Management, ~azlroad
Retirement Board, 844 N. Rush Street, Chicago, IL 606fl-2092.

R o b e r t J. Duda
D i r e c t o r of O p e r. a .t i o n s

Form Approved
OMB NO. 3220-0036
SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE

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1.A. Do you considerthat any person or company was responsible for your
injury or sickness? YESNO
B. If 'YES' give name and address of such person or company.
NAME t
ADDRESS :
2.

Have you filed, or do you expect to file, a claim against such person
or company? YES
NO

3.

Were you injured while on duty?
#

!YES-

NO

4.

Did your sickness result from yous work?

YES-

NO

5.

bLllere did yo,ur injury take place?

6.

What was the date of your injury or accident? MONTH-DAY

-YEAR-

7.A. Were you injured in an automobile accident? YES
NOB. If 'YES' give the following information about the automobiles
involved:
DRIVER OR DRIVERS:
Name :
Name :
Address:
Address :
OWNER OR OWNERS:
Name :
Address:

Name :
Address :

INSURANCE COMPANY OR COMPANIES REPRESENTING DRIVER OR DRIVERS OF
CAR(S) WHICH CAUSED YOUR INJURY (IF KNOWN).
INFORMATION ABOUT YOUR
OWN INSURER IS NOT NEEDED.
Name :
Name :
Address :
Address:
8.

I 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 far withholding
information to cause the payment of benefits by the RRB.

DATE
Return this form promptly to the
address shown on the other side.
Failure to return this form within
30 days could delay payment of
benefits to you.