Form SI-1a (02-01) SI-1a (02-01) Application for Sickness Benefits

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039

Application for Sickness Benefits
Identifying Information
1. Employee's Name First, Middle Initial, and Last)

2. Social Security Number

3.

4. Date of Birth

-

Employee's Street Address, City, State and ZIP Code
(Including Apartment Number)

5. Sex

Year

a Male
a Female

6. Telephone Number (Include Area Code)
I

-

1

Infirmity and Employment Information
7. Date You Became Sick or Injured

8. Date You Last Worked for a Railroad
9.

Last Railroad Employer (Name of Company)

10. Location of Last Railroad Employment (CityIState)

11. Last Railroad Occupation
12. Department

13. If you worked for a nonrailroad employer after the date shown in Item 8, complete Items A, B, and C, below. Otherwise, go to Item 14.

A. Last Nonrailroad Employer (Name of Company)
B. Last Occupation After Railroad Work

a

14. Are you applying for sickness benefits because you were injured at work or have a work-related illness?
Yes
15. Have you filed or do you expect to file a lawsuit or claim against any person or company for personal injury?
Yes -Complete Items A-D, below
No - Go to Item 16
A. Furnish the name and complete address of the person or company.

a

a No

a

City, State, ZIP Code

B. Give the place where the injury occurred.

a Yes a No - Go to Item 16

C. Were you injured in an automobile accident?

D. If you were injured in an automobile accident, provide information about all the vehicles, other than your own, that were
involved in the accident that caused your injury. Information about your vehicle and insurance company is not needed. If you
need more svace attach a se~aratesheet of vaDer.
.

.

Owner of Car (other vehicle)

I

Driver (other vehicle)

Name

1

Name

Address

1

Address

City, State, ZIP Code

1

City, State, ZIP Code

Insurance C o m ~ a n v(other vehicle)

I

Policv Information (other vehicle)

Name

Policy Number
I

Address

1

Claim Number

City, State, ZIP Code
Continued on Next Page

SI- 1a (02-0 1)

16. Enter the earliest date you wish to claim sickness benefits.
17. Are you claiming all the days of sickness beginning with the date you entered in item 16? (Note: You may claim rest days if you
were unable to work and did not receive pay from your employer.)
0 Yes - Go to Item 19 0 No - Go to Item 18
18. Enter any dates that you do not wish to claim.
19. Enter the date you returned to work (if applicable).
20. You
complete all boxes to indicate if you have received or will receive any of the following payments for your days of sickness.
If you check "YES" for any item, be sure to provide the requested information.
A. WAGES (Include Railroad and Nonrailroad Wages)
YES NO If "YES," show the dates for which you were paid in MonthDayNear format below.
Regular Wages. . . . . . ' . . . . . . . . . . .
Vacation Pay. . . . . . . . . . . . . . . . . .
Holiday Pay. . . . . . . . . . . . . . . . . .
Military Reservist Pay . . . . . . . . . .
Wage Continuation Pay . . . . . . . . .
Earnings from Self-Employment . .
Sick Pay from Your Employer. . . .
(but not payments supplementing Railroad Retirement Board (RRB) benefits. See Booklet UB-11)

a a

a

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

a a

a
a
a
a a
a

a
a

a

a

C. OTHER PAYMENTS
YES NO If "YES," complete Items 1 and 2.
Settlement or Damages for Personal Injury
1. Date of ~gyment
Advances
2. Paid By:
Separation Allowance (Buyout, Severance Pay)
21. If the date you are submitting this form is more than 30 days after the date you entered in item 16, answer the following:
A. Why did it take more than 30 days to submit this form? If more space is needed, attach a separate sheet of paper.

a a

a
a a

B. How did you obtain this form?
C. Who provided this form to you?
D. On what date did you obtain the form?
E. Furnish the name and title of any person from whom you asked for help in completing and filing the forms.
NAME
TITLE

Direct Deposit Information
!2. Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To provide the

information we need to correctly deposit your payments, attach a voided personal check and go to Item 23, or call your financial
institution for the information you need to complete Items A-E. If you do not have a bank account, or receiving your payments by
Direct Deposit would cause you a hardship, go to Item E
A. Routing Transit Number

B. Account No.

C. Account Type:
D. Name of Financial Institution:
Checking
Saving
E. Telephone No. (Include Area Code) [
F.
Check this box if you do not have a checking, or savings account, or if Direct Deposit would cause you a hardship.

a
a

a

Certification and Signature
3. I waive any "doctor-patient privilege" I may have with respect to the disclosure of information concerning the period of sickness or injury on

which my claim is based. I certify that I understand and agree to the requirements in Booklet UB-I 1. I know that disqualification 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. NOTE: If the sick or injured employee is unable to
sign h s form, sign your name above and complete Section 1 of the attached Form SI-10, Statement of Authority to Act for Employee.
SIGNATURE
SI-la (02-01)

DATE
HAVEYOUR DOCTOR COMPLETE THE ATTACHED STATEMENT OF SICKNESS