SI-3 (Internet)(pr Claim for Sickness Benefits

Railroad Unemployment Insurance Act Applications

SI-3 (Internet)(proposed)

Railroad Unemployment Insurance Act Applications

OMB: 3220-0039

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3220-0039 can be found here:

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Proposed

Form Approved
OMS 3220-0039

51-3 (xx-xx) Claim for Sickness Benefits
Introduction Page
Welcome to the Railroad Retirement Board's Online Claim for Sickness Benefits.
Only residents of the United States can use this online claim. If you live outside the United
States, mail your paper claim to your nearest RRB field office.
Before completing your claim form, carefully read the section titled "Instructions for
Completing Claims for Sickness Benefits (Form SI-3)" in the Booklet UB·ll (link), Sickness
Benefits for Railroad Employees or Booklet UB-Us (link), Beneficios de Enfermedad para
Empleados Ferroviarios.
IMPORTANT: The time limit for filing your claim is 30 days from the last day of the claim
period or 30 days from the date the form was available on the Internet, whichever is later.
Waiting PeriodlBenefit Payments - If this is your first claim in a period of sickness and you
have not previously satisfied the benefit year waiting period requirement, benefits will be paid
to you for your days of sickness over 7 in the period. Otherwise, benefits are normally payable
for the number of days of sickness over 4 in each claim period.
Allow up to 15 calendar days from the date you submit your claim on the Internet for a
payment to be received. If you do not receive a payment or other notice within 15 days,
contact your local RRB office for information about the status of your claim.
RRB Helpline - For information about the benefits paid to your or to check on the status of
your application or claim form, use the View RUIAAccount Statement service under the Benefit
Online Services or call 877-772-5772 and select option 1.
If you are not currently receiving payments by Direct Deposit and wish to sign up, please
contact your local RRB office.

(xx-xx)

Proposed

Form Approved

OMB 3220-0039

51-3 (xx-xx) Claim for Sickness Benefits
Record of Recent Benefit Payments:
Amount
$xxx.xx
$xxx.xx
$xxx.xx

xx
xx
xx

Claim Beginning
xx-xx-xx
xx-xx-xx
xx-xx-xx

Date AQQroved
xx-xx-xx
xx-xx-xx
xx-xx-xx

(If no recent payments, space will show: No Payments Issued in last 90 Days)
Click here to read these important notices:
• Privacy Act Notice (UNK)
• Computer Matching and Privacy Protection Act Notice(LlNK)
• Paperwork Reduction Act Notice (LINK)
• Nondiscrimination on the Basis of Disability (LINK)
• Fraud and Abuse Hot line (LINK)
Claims(s):

The following claim(s) are available for completion: If you do not wish to file on the Internet,

please file the paper claims we mailed to you. Do not file both a paper and Internet claim for

the same claim period. To begin your claim for sickness benefits, click on one of the claim

periods listed below.

(Claim(s) that are currently available for completion)

Claim(s) Not Available for Completion

xx-xx-xx THROUGH xx-xx-xx (LINK)

(Claim(s) that will be available for completion on the last day of the claim period)

Claim(s) Not Available for Completion

xx-xx-xx THROUGH xx-xx-xx (LINK)

To return to the Benefits Online Services menu to do additional private, secure business with

us, click here (LINK).

(xx-xx)

Page 1 of 1

Railroad Retirement Board - Online Sickness Benefits Claim -- Questions 1 through 3

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About Us

United States of America - Railroad Retirement Board

Providing Secure Intel'11ei Services to the Railroad Commlmi(J'

I Privacy I
Security

Claim for Sickness Benefits -- Form SI-3

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Item 1 - Claim Period Item 4 - Name & Address Item 5 - Wages and Payments Item Ii - Certification

1. This claim is for sickness benefits for Sunday, Mar 01,2009 through Sunday, Mar 15,2009.
To claim benefits, enter or select the appropriate code (X,E,P, or O) in the box under each date
Mar 01

Mar 02

Mar 03

Mar 04

Mar 05

Mar 00

Mar 07

Mar OS

Mar 09

Mar10

Mar 11

Mar 12

Mar 13

Mar 14

L3
L3 13

13 13

L3 13
113
[3 L3 13

X - Claimed day of sickness (Including rest days);
E - Day employed (Include railroad, nonrailroad, or selCemployment);
P - Vacation or holiday pay; (Do not report supplemental sickness
benefits)
- Day not claimed, other reason

Yes

2A. Have you returned to work?

2 B. If"Yes," enter the date you returned to work:

·121

3. Your claim will be processed by this RRB
Office:

51-3 (xx-xx)
Form Approved
OMB No. 3220-0039

Last Revised
07/08

844 North Rush
9TH FLOOR
CHICAGO IL60611 -2092
(312)751-4500

Remember that you ..!.
cannot claim
benefits for any day
on which you
worked or
otherwise earned
regular wages,
vacation pay,
holiday pay, military
reservist pay, wage
continuation pay,
sick pay (excluding
supplemental
..:J

This is an official U.S.Government website

http://rrbappc2/webappsIRUIANetSBIRUIANetSBPlQl 3.aspx

2/26/2010

Page 1 of 1

Railroad Retirement Board - Online Sickness Benefits Claim -- Late Filing Page

I1l.l~H}OUT ~ I(D.
About Us

United States of America· Railroad Retirement Board

Prol'iding Secure Intemet Sen'ices to tlte R"ilroad C(}mmtlni~I'

I Privacy I
Security

Claim for Sickness Benefits -- Form SI-3
Items 1-3 - Claim Period Item 4 - Name & Address Item 6 - Wages and Payments Item .. - Certification

The time limit for filing your claim is 30 days from the last day of the claim period or 30 days from the

date the form was mailed to you and made available to you online. whichever is later.

If you tried to file your claim earlier but were prevented from doing so by circumstances beyond your

control. your claim may be considered as filed on time.

An employee's lack of knowledge about the filing requirements is not considered to be a circumstance

beyond his or her control.

Please provide the following information in the space below for your explanation for late filing:

What actions did you take to obtain and complete your claim for sickness benefits? Provide the

dates you tool these actions.

Provide the names and titles of any persons who helped you complete and file your claim.

Characters
Remaining:

1750
IPrevious pagel

..::::J

Your claim should
be filed within
later of 30 days
after claim end
date or after the

...

~~!~ ~~~.~:I:'..i~_was ..::::J

SI-3 (xx-xx)
Form Approved
OMB No. 3220-0039

Last Revised
07/08

This is an official U.S. Government website

http://rrbappc2/webappsIRUIANetSI3IRUIANetSI3P2LateFiling.aspx

2/2612010

Page 1 of 1

Railroad Retirement Board - Online Sickness Benefits Claim -- Question 4

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United States of America

1l1(B.

About Us

Railroad Retirement Board

Prol'icli11g Secure /11temet Serl'ices to tlte Railr()(ul Commu11ity

I Privacy I
Security

Claim for Sickness Benefits -- Form SI-3
Items 1-3 - Claim Period Item 4 - Name & Address Item 5 - Wages and Payments Item 6 - Certification

If your name or address is incorrect, make corrections below.

Name (First Init, Mid Init,
Last)

Mailing Address

*
*

Address Continued
City

State

IState

ZIP Code

Phone Number

l.r---I

81-3 (xx-xx)
Form Approved

This item is prefilled .....
with your name and
address. If
necessary, make
corrections to your
name and address
in the box.

[previOUS Pagel

OMB No. 3220-0039

Last Revised
07/08

This is an official U.S.Government website

http://rrbappc2/webappsIRUIANetSI3IRUIANetSI3P3Q4.aspx

2/2612010

RaHroad Retirement Board - Online Sickness Benefits Claim -- Question 5A Regular Wa...

United States of America

Railroad Retirement Board

Page 1 of 1

AbQ!ltU8

PrOl'idillg Secure Illternet St.:'1"l'ltces to tile Railroad Commul1ity

I Privacy I
Security

Claim for Sickness Benefits -- Form SI-3

Items 1-3 - Claim Period

It~m

4 - Name & Address Item 5 - Wages and Payments Item 6 - Certification

Questions
SA 5-7 ~ 581-3
58 4-6 ~ 5C
You must click" Yes" or" No to show if you have received or will receive each of the
following payments for your days of sickness
II

SA. Wages (Include railroad and nonrailroad
wages) -If "Yes," enter dates for which paid in
M/DN format.

YES

1 Regular Wages

*R"

:d
..:J
2 Vacation Pay

*R"

Enter dates for
which paid in
Month/DayNear
format

Od
..:J
3 Holiday Pay

*rv:

Od
..:J
4 Military Reservist Pay

*R"

:d
..:J

81-3 (xx-xx)

Form Approved
OMB No. 3220-0039

Last Revised

IpreViOUS pagel

This is an official U,S.Government website

07/08

http://rrbappc2/webappsIRUIANetSI3IRUIANetSI3P4Q5AI_4.aspx

2/26/2010

Railroad Retirement Board - Online Sickness Benefits Claim -- Question SA Wage Conti...

Page 1 of 1

About Us

United States of America - Railroad Retirement Board

I Privacy I

Providing Secure Internet SL'Tvices to tlte Railroad Community

Security

Claim for Sickness Benefits -- Form SI-3

Items 1-3 - Claim Period Item 4 - Name & Address Item 5 - Wages and Payments Item 6 - Certification

5A 1-4 , 58 1-3 ~ 58 4-6 ~ 5C
~

You must click" Yes" or" No "to show if you have received or will receive each of the

following payments for your days of sickness

Questions

5A. Wages (Include railroad and nonrailroad wages) - If
"Yes," enter dates for which paid in M/DN format.

YES

*P"
:d

5 Wage Continuation Pay

Dec/S/07, 12/612007

..:J

*P"
:d

6 Earnings From Self-Employment

101112/09, Jan/14/2009

..:J

7 Sick Pay From Your Employer

SI-3 (xx-xx)
Form Approved
OMB No. 3220-0039

Last Revised

IpreViOUS pagel

Wage Continuation
Pay - Salary or
wages paid by your
railroad employer
when you have
been injured onduty. The purpose
of the payments is
to continue your
wage or: salary, not
to supplement RR8
benefits. The
payments are

....

..:J

This is an official U.S.Government website

07/08

http://rrbappc2/webappsIRUIANetSBIRUIANetSBPSQSAS_7.aspx

2/26/2010

Railroad Retirement Board - Online Sickness Benefits Claim -- Question 5B Government... Page 1 of 1

Apout Us I Privacy

United States of America - Railroad Retirement Board

Prol'i<1ing Secure Intemet SelTices to tbe Railroad Community

§ecurity

Claim for Sickness Benefits -- Form SI-3

Items 1-3 - Claim Period Item 4 - Name & Address Item 5 - Wages and Payments Item 6 - Certification

Questions
5A 1-4'
·5A 5-7
5B 4·6 ~
...5C--.......

You must click "Yes" or "No" to show if you have received or will receive any of the following

payments for your days of sickness

5B. Governmental Payments (Not RRB Sickness Benefits)
If "Yes," enter the Date, Amount, and how often for any item.
1 Sickness or Unemployment Benefits Under Any Other
Law
1. Beginning Date of Paymen 2. Gross AmoLint of Payment

$
2 Social Security Benefits
1 Beginning Date of Paymen 2, Gross AmoLint of Payment

.::J

NO Sickness or
Unemployment
rv' Benefits under
any Other Law
are benefits paid
to you on account
How often do you receive the payment?
of sickness or
unemployment by
a county, city or
state government,
or by another
r Federal agency.
Governmental
YES

3, How often do YOLI receive the payment?

3 Railroad Retirement or Disability Annuity
1, Beginning Date of Paymen 2, Gross Amount of Payment

.::1

51-3 (xx-xx)
Form Approved

3, How often do YOLI receive the payment?

IpreViOUS Pagel

. Next Page

OMB No. 3220-0039

Last Revised
07/08

This is an official U,S,Government website

http://rrbappc2/webappsIRUlANetSI3IRUlANetSI3P6Q5Bl_3.aspx

2/2612010

Railroad Retirement Board - Online Sickness Benefits Claim -- Question 5B Military Reti... Page 1 of 1

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1'(1(il.

About Us

United States of America - Railroad Retirement Board

Providing Secure Internet Services to the Rai/roal/ Community

I Privacy I
Security

Claim for Sickness Benefits -- Form SI-3

Items 1-3 - Claim Period Item 4 - Name & Address Item 5 - Wages and Payments Item 6 - Certification

SA 1-4
SA 5-7 ~
58 1-3 ~
5C
,

You must click" Yes U or II No " to show if you have received or will receive any of the following

payments for your days of sickness

Questions

5B. Governmental Payments (Not RRB Sickness Benefits)
If "Yes," enter the Date, Amount, and how often for any item.
4 Military Retirement Pay
1. Beginning Date of Pay men 2. Gross Amount of Payment

NO Military
....
Retirement Pay is
an a~nuity.
pension or
retainer pay paid
How often do you receive the payment?
to you by the
Federal
Government
based on you
military service.
Governmental
payments are
How often do you receive the payment?
annuities or other ..:::J

YES

5 Worker's Compensation
1. Beginning Date of Paymen 2. Gross Amount of Payment

6 Retirement Payments Under Another Law
1. Beginning Date of Paymen 2. Gross Amount of Payment

SI·3 (xx·xx)
Form Approved

3. How often do you receive the payment?

IpreviOUS pagel

OMS No. 3220-0039

Last Revised

This is an official U.S.Government website

07/08

http://rrbappc2/webappsIRUIANetSI3IRUIANetSI3P7Q5B4_6 .aspx

2/26/2010

Railroad Retirement Board - Online Sickness Benefits Claim -- Question 5C Other Wages

United States of America

Page 1 of 1

About Us

Railroad Retirement Board

PrOl'itliltg Secure Internet Services to tlte Railroad Community

I Privacy I
Security

Claim for Sickness Benefits -- Form SI-3

Items 1-3 - Claim Period Item 4 - Name & Address Item 5 - Wages and Payments Item 6 - Certification

Questions
5A 1-4 ~
5A 5-7
58 1-3
58 4-6
You must click It Yes It or" No " to show if you have received or will receive each of the following
payments for your days of sickness

5C. Other Payments - If "YES," give the date of payment
and who made the payment to you.

YES

1 Settlement or Damages for Personal Injury

1. Date of Payment

2. Paid by

151
2 Advances
1. Date of Payment

2. Paid by

zj
3 Separation Allowance (Buyout, Severance Pay)
1. Date of Payment

....
Settlement or
Damages for
Personal Injury -A
payment received
as a result of a
'udgement or the
settlement of a
personal-injury
claim against your
railroad employer or
another party that
you held liable for
your injury or
~

2. Paid by

SI-3 (xx-xx)

Form Approved

IpreViOUS pagel

OMB No. 3220-0039

Last Revised

This is an official U.S.Government website

07/08

http://rrbappc2/webappsIRUIANetSI3IRUIANetSI3P8Q5C.aspx

2126/2010

RaIlroad Retirement Board ~ Online Sickness Benefits Claim -. Review Claim

United States of America - Railroad Retirement Board

Page 1 of3

About Us

PrOl.idil1g Secure Interllet Sen'ices to tile RlIilroad Commullity

I Privacy ,I
Security

Claim for Sickness Benefits -- Form SI-3
Items 1-3 - Claim Period Item 4 - Name & Address Item S - Wages and Payments Item 6 - Certification

Claim Review and Certification Statement

Were you able to complete this claim
form yourself?

Yes No
(it'
r

Please review your answers below. To make corrections, click on the tabs above to return to

the section of the application you want to correct. After making any corrections, click on the

"Certification" tab at the top of the page to return to this page. Then complete the

Certification at the bottom.

Your Name:
1. This claim is for sickness benefits for the period August 01, 2008 through
August 14, 2008.

August 01
August 02
August 03
August 04
August 05
August 06
August 07
August 08
August 09
August 10
August 11
August 12
August 13
August 14

P - Vacation or holiday pay

X - Claimed day of unemployment (Includil'1g rest days)

E - Day employed

Day not claimed, other reason

X - Claimed day of unemployment (Including rest days)

Day not claimed, other reason

P - Vacation or holiday pay

o - Day not claimed, other reason

E - Day employed

X - Claimed day of unemployment (Including rest days)

P - Vacation or holiday pay

Day not claimed, other reason

P - Vacation or holiday pay
X - Claimed day of unemployment (Including rest days)

oo-

2a. Have you returned to work? Yes

2b. If Yes, the date you returned to work - August 15,2008

3. Your claim will be submitted to the following address:
U.S. Railroad Retirement Board

DO Line 1

DO Line 2

DO Line 3

http://rrbappc2/webappsfRUIANetSI3IRUIANetSI3P 1OSubmit.aspx

2/26/2010

Railroad Retirement Board - Online Sickness Benefits Claim - Review Claim

Page 2 of3

DO Line 4

4. Your Address:
123 Main Street
P.O. Box 321
Fort Worth, TX 76102
817-978-2468
5a. WAGES (Includes railroad and nonrailroad wages) -If "Yes," show dates you were
paid.

No
No

servist Pay
Wage Continuation Pay
Earnin From Self Emplo ment
Sick Pay from Your Employer (but not payments
u lementin RRB benefits)

No
Yes

Aug 16-28,08

PAYMENTS Not RRB sickness benefits
Gross
B.eglnning Date Amount of
Yes/No of Payment
Payment

Payments
Sickness or Unemployment
Benefits Under Any Other
Law
. . Yes·
IF=~================
. ocial Securit Benefits
Railroad Retirement or
Disability Annuity
Milita Retirement Pay
Worker's Compensation
Retirement Payments Under
Another Law
No

12.30

1/10/2001

How Often

Weekly

3/10/2001

Yearly

5/10/2001

Weekly

!5c. OTHER PAYMENTS
Payments

Yes/No

Date OT
Payment

http://rrbappc2/webappsIRUIANetSI3IRUIANetSI3P 10Submit.aspx

Paid by
2/26/2010

Page 3 of3

Railroad Retirement Board - Online Sickness Benefits Claim - Review Claim

Settlement, Damages or Advances for
Personal Injury
Advances
Separation Allowance (Buyout, Severance
Pay)

Yes

7/10/2001

Not Board

Your Payments Will be Made Electronically by Direct Deposit to the Account Shown
Below:

Routing
Number
Financial
Organization
Account
Number
Type of
Account
~lickHereto Change Your Direct Deposit Infonnation

Late filing
explanation:

I was on vacation
.. CUd< Here to Change Your Late Hiing. Explanation

CERTIFICATION:

I certify that I understand and agree to the requirements in Booklet UB-11. I know that

disqualifications 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 inforrnation given on this form is true, correct, and complete .

. .1Agree and Su~mit this Claim ......... 1

Delete Claim Answers

51-3 (xx-xx)
Form Approved .
OMS No. 3220-0039

This is an official U.S.Government website
Last Revised
07/08

http://rrbappc2/webappsIRUIANetSI3IRUIANetSI3P10Submit.aspx

2/26/2010

Page lof3

Railroad Retirement Board - Online Sickness Benefits Claim -- Thank: You Page

. . -:-:~
.~

"'\.s
.....

United States of America - Railroad Retirement Board

About Us I Privacy

Providing Secure intemet SeTl';ces to tire Railroad CommultuJ'

Claim for Sickness Benefits -- Form SI-3

Security
81-3 (xx-xx)
Form Approved
OMB No. 3220-0039

February 26, 2010, 1:59 PM
Thank you for using the RRB's "Benefit Online Services (Mainline)" to file your claim for
unemployment benefits. Please do not file a paper claim for the same claim period.
The following information has been submitted as of Friday, November 21, 2008 at 10:00 AM.
Please print a copy of this screen for your records.
Please allow 15 days to receive your payment. That amount of time is needed to allow your
employer to give us information about your claim arid for processing and delivery of your
payment. Contact your local RRB office if you do not receive a payment or letter within this
time period.
You should expect to receive your next claim by mail within 15 days if you are still
unemployed and have not exhausted your benefits. If you do not receive the claim,
please contact your localRRB office.

To return to the Benefit Online Services (Mainline) Menu to do additional private, secure
business with us;
To leave the PIN-password protected Benefit Online Services (MainUne) area,
Your Name:

1. This claim is for slcJFile Type application/pdf
File Modified 2010-07-26
File Created 2010-07-26

File Type	application/pdf
File Modified	2010-07-26
File Created	2010-07-26