Information Collection

Supplemental Information on Accident and Insurance

IC 187866 under ICR 200901-3220-002 · OMB 3220-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ID-3s (proposed) Supplemental Information on Accident and Insurance	Form and Instruction
SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefit Form SI-5 (12-93).pdf	Form and Instruction
ID-3S (06-05) Request for Lien Information Form ID-3S (06-05).pdf	Form and Instruction
ID-3S-1 Lien Information Under Section 12(o) of the RUIA Form ID-3S-1 (03-02).pdf	Form and Instruction
ID-3U (03-02) Request for Section 2(f) Information Form ID-3u (03-02).pdf	Form and Instruction
ID-30K-1 (03-02) Request for Supplemental Information on Injury or Illnes Form ID-30K-1 (03-02).pdf	Form and Instruction
ID-3s (proposed) Request for Lien Information Form ID-3s (proposed).pdf	Form and Instruction
ID-3S-1 (proposed) Request for Lien Information, Report of Settlement of Th Form ID-3S-1 (proposed).pdf	Form and Instruction
ID-3U (proposed) Request for Section 2(f) Information Form ID-3u (proposed).pdf	Form and Instruction
Form ID-30B-1 (02-99).pdf Notice of Lien Transmittal Letter	IC Document
Form ID-30B-2 (02-99).pdf Notice of Lien Transmittal Letter	IC Document
Form ID-30B (02-99).pdf Notice of Lien Transmittal Letter	IC Document
Program Letter(2-06) E-Mail requests.pdf Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements	IC Document
Form ID30D1 (04-06).pdf ID-30D-1, Request for Information on Injury or Illness	IC Document

IC Title:

Supplemental Information on Accident and Insurance

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 340 20 CFR 341

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ID-3s (proposed)	Request for Lien Information	Form ID-3s (proposed).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-3S-1 (proposed)	Request for Lien Information, Report of Settlement of Third Party Liability Cases	Form ID-3S-1 (proposed).pdf	No		Paper Only
Form and Instruction	ID-3U (proposed)	Request for Section 2(f) Information	Form ID-3u (proposed).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	SI-5 (12-93)	Report of Payments to Employee Claiming Sickness Benefits Under the RUIA	Form SI-5 (12-93).pdf	No		Paper Only
Form and Instruction	ID-3S (06-05)	Request for Lien Information	Form ID-3S (06-05).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-3S-1	Lien Information Under Section 12(o) of the RUIA	Form ID-3S-1 (03-02).pdf	No		Paper Only
Form and Instruction	ID-3U (03-02)	Request for Section 2(f) Information	Form ID-3u (03-02).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-30K-1 (03-02)	Request for Supplemental Information on Injury or Illness - 3rd party	Form ID-30K-1 (03-02).pdf	No		Paper Only

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records

Title: RRB-21, Railroad Unemployment and Sickness Benefit System

FR Citation: 73 FR 73514

Number of Respondents: 7,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 66 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	25,500	25,500
Annual IC Time Burden (Hours)	1,443	1,443
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Notice of Lien Transmittal Letter	Form ID-30B-1 (02-99).pdf	01/26/2009
Notice of Lien Transmittal Letter	Form ID-30B-2 (02-99).pdf	01/26/2009
Notice of Lien Transmittal Letter	Form ID-30B (02-99).pdf	01/27/2009
Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements	Program Letter(2-06) E-Mail requests.pdf	01/27/2009
ID-30D-1, Request for Information on Injury or Illness	Form ID30D1 (04-06).pdf	01/27/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.