ID-3S-1 (proposed) Request for Lien Information, Report of Settlement of Th

Form Approved
OMB No.3220-0036

United States of America
Railroad Retirement Board

1. Please Indicate
From:/To:

LIEN INFORMATION
UNDER SECTION 12(0)
OF THE
RAILROAD UNEMPLOYMENT
INSURANCE ACT

1

Date

(Law Firmllnsurance Company)

(Phone Number)

3.

(Facsimile Number)

U.S. Railroad Retirement Board
Office of Programs Operations
Attn: Claims Adjustment and Settlement Section
844 North Rush Street
Chicago, Illinois 60611-2092
Telephone Number: (312) 751-4820
Facsimile Number: (312) 751-7185
6.

5.

4.

Employee's Name

2. Please Indicate
To:IFrom:

-

(Name of Inquirer)

(See Important Notices Below)

I

Social Security N u m b e r

Date of Injury

RRB Use Only
Lien Amount

Yes
No
Notices:

This is in response to your inquiry about benefits recoverable under section 12(0) of the Railroad Unemployment Insurance Act (RUIA). The
Railroad Retirement Board's (RRB) completed reply is confirmation of the amount of the RRB's lien. No confirmation letter will be provided.
* If th lien amount shown is "Not Final," the amount is valid for settlement and reimbursement purp.ses
ONLY if you inform the RRB within 5 days
th&ttlement
has been made. Regulations require that you notify the RRB within 5 days oftsettlement or judgment and that you pay the
RRBYhe amount withheld to satisfy the lien within 30 d ~ y of
s the date of the settlement orjudgment. Amounts that are not paid within
30 days are subject to interest charges from the date oc.ettlement or judgment. If we do not receive such a notice within 5 days, the amount
recoverable may be increased by the payment of additional benefits. After 5 days, we will provide, upon request, an updated figure on the amount
of benefits paid.

If a case has reached a settlement, the RRB should be reimbursed for the amount of our lien. The amount of reimbursement should be sent in the
of a check or money order made payable to the Railroad Retirement Board. Please show the employee's social security number and the date
oqsettlement on your remittance.

for^

-

Attorney's fees The RRB's regulations (20 CFR 341.9) provide that the RRB shall not be liable for the payment of any attorney's fee or other
expenses incurred in connection with any personal-injury claim.

-

.i

Statutory lien The RRB does not have a subrogation claim, but does have a right to reimbursement protected by,,Federal statutory lien set
forth in section 12(0) of the RUIA (45 U.S.C. 362(0)).
(RRB Representative)
(Date Returned)

INSTRUCTIONS
Please complete Items 1-5 and send this form via facsimile (fax) to the Railroad Retirement Board, Office of Programs - Claims Adjustment and
Settlement Section at (312) 751-7185.
ITEM
1.

Circle the appropriate sender designation and enter the name of the law firm or insurance company making the inquiry, including the other
identifying information as requested (i.e., name of the inquirer, telephone and fax numbers and the date). For example, if the Form ID-3s-1 is
being faxed to the Railroad Retirement Board, circle "From:" and complete the remaining items.

2.

Circle the appropriate receiver designation. For example, if the Form ID-3s-1 is being faxed from the Railroad Retirement Board, circle
"From:." Item 1 must be addressed to the inquirer.

3.

Enter the employee's name beginning with the first initial, middle initial, and full last name. Do not enter a partial name.

4.

Enter the employee's social security number.

5.

Enter the earliest date of occurrence of the injury for which a settlement is being made. If more than one injury is being settled, enter
applicable dates.

6.

FOR RRB USE ONLY.

p&&$'

Paperwork Reductior)(PrivacyAct Notice - The Railroad Retirement Board i s authorized to collect the information requested on Form ID-3s-1
under section 5(b) of the Railroad Unemployment Insurance Act (RUIA). The information is needed to determine the amount of sickness benefits
reimbursable under section 12(0) of the RUIA. Because you are required to provide this information under section 9(a) of the RUIA, failure to
complete and return this form could result in a fine or imprisonment or both.
We estimate this form takes an average of 3 minutes to complete, including the time for reviewing the instructions, getting the needed data, and
reviewing the completed form. Federal agencies may not conductor or sponsor, and respondents are not required to respond to, a
information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our estimate or any
Railroad Retirement Board, 844 North
form, including suggestions for reducing completion time, to the Chief of
Street, Chicago, Illinois 60611-2092.