Supplemental Information on Accident and Insurance

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form SI-1C (03-02) Supplemental Information on Accident and Insurance Form and Instruction
SI-1C (03-02) Supplemental Information on Accident and Insurance Form SI-1c (03-02).pdf Form and Instruction
SI-1c (proposed) Supplemental Information on Accident and Insurance Form SI-1c (proposed).pdf Form and Instruction
ID-30K (03-02) Form Letter Asking Claimant for Additional Information o Form ID-30K (03-02).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Information on Accident and Insurance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 340 20 CFR 341

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	SI-1C (03-02)	Supplemental Information on Accident and Insurance	Form SI-1c (03-02).pdf	No	Paper Only
Form and Instruction	SI-1c (proposed)	Supplemental Information on Accident and Insurance	Form SI-1c (proposed).pdf	No	Paper Only
Form	ID-30K (03-02)	Form Letter Asking Claimant for Additional Information on Injury or Illness	Form ID-30K (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 Insurance Benefit System	FR Citation: 73 FR 73514

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,000	-25,500	28,500
Annual IC Time Burden (Hours)	250	-1,443	1,693
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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