UB-11, Sickness Benefits for Railroad Employees

Sickness Benefit
Application Enclosed

Sickness Benefits

for

Railroad Employees

United States of America
Railroad Retirement Board
Visit our Web site at www.rrb.gov

Form UB-11

CONTENTS

Introduction

1

Qualification Requirements
Amount and Duration of Benefits
Waiting Period
Normal Benefits .....
Extended Benefits ...
Accelerated Benefits ..
Daily Benefit Rate
Number of Days of Sickness
Tier I Tax Deductions

2

2
2
................ 2
................... 2
3
3
3

Eligibility Requirements

3

Medical Statements

3

Sick Pay and Supplemental
Sickness Benefits

4

Disqualifications
Separation Allowance .
False or Fraudulent Claim
Benefits Under Other Laws ... ....... . . .. ............
Medical Examination

4
4
4
4

Benefit Reductions

4

Personal Injury Settlements ..

... 4

Reconsideration and Waiver
Employee Rights
Employer Rights

5

When Sickness Benefits are Taxable

5

5

Instructions for Completing Forms
.......
General Instructions
Important Information ...............................................
Application for Sickness
Benefits (SI-la) ...
Statement of Sickness (SI-lb)
Statement of Authority
to Act for Employee (SI-I0)
Claim for Sickness Benefits (SI-3)
Notices
Privacy Act
Computer Matching and Privacy
Protection Act
Paperwork Reduction Act
Nondiscrimination on the·Basis
of Disability .....
. Checking Your Benefits by Telephone

5
5
6
8

8
8

10
10
11
11

12

Important Reminders

13

Fraud and Abuse Hot Line

13

INTRODUCTION

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IF YOU ARE UNEMPLOYED, you may be eligible to receive
unemployment benefits from the Railroad Retirement Board
(RRB), the Federal agency responsible for administering the
Railroad Unemployment Insurance Act (RULA). This booklet
provides information about the requirements for receiving rail­
road unemployment insurance benefits, the amount of benefits
payable an~_ procedures for claimiIlgJtenef1ts.

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how to open a PPW account.
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If you become sick or injured, you may be eligible to receive
sickness benefits. Those benefits are described in the booklet
UB-II, Sickness Benefits for Railroad Employees, which can be
obtained from any RRB office, your employer~ your labor orga­
nization, or the RRB's Web site at www.rrb.gov.
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Be sure to read the important notices at the back of this
booklet about the Privacy Act, Paperwork Reduction Act,
Computer Matching and Privacy Protection Act, and the
Rehabilitation Act.

This booklet contains general information and does not have
the effect of law. regulation, or ruling. Certain exceptions,
limitations, and special cases are not covered. If you have any
questions about unemployment or sickness benefits, contact
the nearest office of the RRB. When writing to the RRB, be
sure to include your social security number.
Spanish translation booklets concerning railroad unemployment
and sickness benefits are available from any office of the RRB.
Tenemos un librete en Espanol que explica los beneficios de los
desempleados del ferrocarril. Lo pueden obtener en su oficina
mas cercana del RRB.

1

Qualification Requirements

Base Year - Benefit Year

Only qualified employees can receive benefits under the
Railroad Unemployment Insurance Act. A new benefit
year begins every July 1. To qualify for benefits in a bene­
fit year, you must have creditable railroad earnings in the
preceding calendar year (base year), counting no more
than a certain amount in any month. In addition, a new
employee must have railroad service in at least 5 months
of his or her first year of work in order to be eligible for
benefits in the following benefit year.
The amount of earnings needed to qualify for benefits in a
benefit year depends on the monthly compensation base in
the base year. An employee is required to have base year
earnings of not less than 2-1 /2 times the monthly compen­
sation base applicable to months in that base year. As the
monthly compensation base increases, the amount of
compensation needed to qualify for benefits also increases.

Example
Benefit Year Beginning July 1, 2009
Earnings Needed in Base Year-$3,200.00 in 2008 (2-1/2 x
$1,280.00=$3,200.00). If 2008 was your first year of rail­
road work, you must also have railroad service in 5
months in 2008.
In this example, $1,280.00 is the monthly compensation
base for base year 2008. The monthly compensation base
for base year 2009 is $1,330.00.
Contact your local RRB field office if you need informa­
tion about the monthly compensation base for other
years.

Amount and DuraHon
of Benefits
WatHng Period
To satisfy a one-week waiting period requirement, no
benefits are payable for your first 7 days of sickness in
your first claim in a period of continuing sickness,
unless you have already served a waiting period in the
benefit year. Benefits are payable for each remaining
day of sickness in your first claim. For example, if you
claim all 14 days in your first claim, you will be paid
benefits for 7 days. If you are eligible and your claims
are continuous from one benefit year to another, you
generally will serve only one waiting period in your
period of continuing sickness.

2

If you have at least 4 consecutive days of sickness and 5
days of sickness overall, you should file a claim for
benefits. Even though no benefits may be payable if the
claim is your first claim in the benefit year, your claim
must be filed in order to satisfy the waiting period
requirement. If you have more than 7 days of sickness in
your waiting period claim, benefits will be paid for the
number of days of sickness over 7. After your first claim,
benefits will be paid for all days over 4 for other claims in
the benefit year.
A "period of continuing sickness" means either (1) a peri­
od of consecutive days of sickness, whether from one or
more causes, or (2) a period of successive days of sickness
due to a single cause without interruption of more than
90 consecutive days which are not days of sickness.

Normal Beneflts
You can receive normal benefits for as many as 130
days (26 weeks) in a benefit year, but your benefits
cannot be more than your base year wages counting
not more than a prescribed amount for any month.
Benefit rights are exhausted when a benefit year ends
(normally June 30) or earlier if benefit payments equal
base year creditable earnings.

Example
For purposes of determining maximum normal benefits
payable in the general benefit year beginning July 1, 2009,
monthly earnings of up to $1,653.00 are counted for
months in base year 2008. For base year 2009, the monthly
compensation base for maximum benefits is $1,718.00.

Extended Beneflts
If you have 10 or more years of service and exhaust your
normal sickness benefits, you may be eligible to receive
extended benefits for up to 65 days (7 consecutive 14-day
claim periods having 10 days payable in each). Also, if you
are not qualified for benefits in the current benefit year, but
received normal benefits in the previous year, you may still
be eligible for extended benefits.

To qualify for extended benefits, you must not have vol­
untarily retired. Extended sickness benefits are not
payable once you attain age 65.

Accelerated Beneflts
Under certain special provisions, if you have 10 or more
years of service, you can receive benefits before the regular
beginning date of a benefit year. To qualify, you must be
qualified for the next benefit year, but not the current year.
You must also have 14 or more consecutive days of sick­
ness and not have voluntarily retired. Accelerated sickness
benefits are not payable once you attain age 65.

Dally Beneftt Rate
Your daily benefit rate is 60 percent of the daily rate of pay for
your last job in the base year, but not less than $12.70 a day or
more than 5 percent of the monthly compensation base.
For example, the monthly compensation base for 2008 is
$1,280.00, which results in a maximum daily benefit rate of
$64.00 for periods beginning after June 30, 2009. The maxi­
mum benefit rate is subject to increases under indexing rules
reflecting the growth in average national wages. Contact
your local RRB field office if you need information about the
maximum benefits rates for other periods.
Your daily rate of pay is your straight-time rate of pay
including any cost-of-living allowances, but not including
overtime or other extra pay.
For mileage employees in train and engine service, the
straight-time rate is the rate of pay for the number of
miles in a basic workday, depending on occupation and
class of service. Earnings for miles run over the number
of miles in a basic workday do not count.

Number of Days of Sickness
After you have satisfied the benefit year waiting period
requirement, benefits are generally paid for days of
sickness over 4 in 14-day claim periods.

TIer I Tax Deductions
Except for benefits paid for on-the-job injuries, sickness
benefits are subject to Tier I railroad retirement taxes if
paid within 6 months after the month in which you last
worked. Tier I tax deductions reduce the amount of bene­
fits payable for a claim.

EliglbilHy Requirements

the section Sick Pay and Supplemental Sickness
Benefits on page 4);
• obtain an application for sickness benefits (51-1a) from
your employer, labor organization, or RRB office;

• have your doctor complete the statement of sickness
(SI-1b) in support of your claim for sickness benefits; and
• complete and file the application for sickness benefits
within 10 days of the first day you become sick or
injured. You may lose benefits if you file late. An
application is considered filed on the day it is received
by any office of the RRB.

Medical Statements
To receive sickness benefits, you must have your doctor
complete a statement of sickness (SI-la) in support of
your claim. In addition, you may be asked to have your
doctor provide the RRB with additional (supplemental)
medical information in order to continue to receive your
sickness benefit payments. How often supplemental
medical information is required depends on several fac­
tors, including when you are expected to return to work.
In determining when you may return to work, we con­
sider your diagnOSis, medical condition, age, normal
occupation and the estimated disability period previously
provided to the RRB by your doctor.
A statement of sickness may be completed by:
• a licensed medical doctor trained in medical and
surgical diagnosis;
• a licensed dentist in cases of infirmity relating to the
teeth and gums;
• a licensed podiatrist if the infirmity relates to the feet;

To receive sickness benefits you must:

• be unable to work due to sickness, injury, pregnancy,
or the birth of a child;

• receive no wages, salary, pay for time lost. vacation
pay, holiday pay, military reservist pay, pay under a
wage continuation plan" sick payor other remunera­
tion from railroad or nonrailroad employment for the
days you claim benefits. You must report such pay on
your claim. However, payments under your own
health or accident insurance policy, or group insurance
policy, or under a supplemental sickness benefit plan
administered by your employer or an insurance com­
pany do not prevent the payment of sickness benefits
and should not be reported on your claim forms (see

• a licensed chiropractor;
• a licensed dodor of clinical psychology;
• a certified nurse/midwife in cases of pregnancy, mis­
carriage, or childbirth;
• a superintendent or other supervisory official of a
hospital, clinic, or similar organization;
• a Christian Science practitioner;
• a Physician Assistant - Certified; or
• a nurse practitioner.

3

Sick Pay and

Supplemental Sickness Bene'fits

Sickness benefits are not payable for any day for which
you receive sick pay from your employer. But benefits
may be paid if you receive supplemental sickness benefits
from your employer or an insurance company. Sick pay is
a continuation of part or all of your wages while you are
unable to work. Sick pay is generally subject to all regular
payroll deductions. You must report sick pay on your
claim form; failure to do so may result in an overpayment
of RRB sickness benefits that you will have to refund.
Supplemental sickness benefits are different from sick
pay. Supplemental sickness benefits are payments made
by your employer or an insurance company to supple­
ment your RRB benefits and are not subject to Tier II
retirement tax. Supplemental benefits are paid under
plans submitted by your employer and approved by the
RRB. Do not report supplemental sickness benefits on
your claim. If you do not know whether payments you
are receiving are supplemental under an RRB-approved
plan, contact the RRB office nearest you for assistance.

Disqualifications
Separa110n Albwance (severance pay, buyout)

medical examination when required, you may be disqual­
ified from receiving sickness benefits.

Benefit Reductions
Benefits are not payable to you in the full amount if you
are also receiving:
• social security benefits,
• a pension, annuity, or other retirement pay under a
Federal, State, or local law (such as a railroad retire­
ment annuity, military retirement pay, a policeman's
or fireman's pension, etc.),
• certain workers' compensation payments, or
• any other social insurance payment under any law.
If you meet the other eligibility requirements, you may
receive benefits only in the amount by which your sick­
ness benefits exceed the other payments.

Be sure to report all such other payments on each claim
you file. If you do not, you may later be required to
refund benefits. If the other payments are awarded after
you claim sickness benefits, but cover some or all of the
same days, contact the RRB immediately about repay­
ment of the benefits you received.

If you have been paid a separation allowance by your

If you are awarded an annuity under the Railroad

employer, you cannot receive sickness benefits for
approximately the period of time it would have taken
you to earn the amount of the allowance.

Retirement Act that is for days you were already paid
sickness benefits, you will have to refund some or all of
your benefits. Generally, the amount you must repay is
withheld from your accrued annuity. Your annuity
award letter or notice of annuity adjustment will show
the amount of any sickness benefits withheld. Verify the
amount by comparing it to the amount of sickness bene­
fits you received for the same period. Contact your local
RRB office immediately if you believe the amount with­
held is incorrect. You will be required to refund benefits
to the RRB if the full amount was not withheld from your
accrued annuity.

False or Fraudulent Claim
You will be disqualified for both unemployment and sick­
ness benefits for 75 days if you make a false or fraudulent
statement or claim in order to receive benefits. You may
also be subject to fine or imprisonment. The RRB conducts
checks, including computer matching checks, with State
and Federal agencies as well as railroads, in order to detect
fraudulent benefit claims.

BenefHs Under other Laws
You will be disqualified from receiving railroad sickness
insurance benefits for any day for which you:
• receive sickness benefits under arty other law; or
• receive unemployment benefits under the Railroad
Unemployment Insurance Act or any similar law.

Medical Examlna110n
In certain situations you may be required to be examined
by a doctor selected by the RRB. If you fail to take the

4

Personal InJury Seffiements
You may receive benefits for any kind of injury or illness
whether it occurs on or off the job; but if you are paid a
settlement or collect damages as a result of the injury or
illness, the amount of your benefits must be refunded to
the RRB. This is true regardless of a State's "no-fault" law.
The RRB will normally notify the liable party, and the per­
son or company making the settlement or paying the
damages usually reimburses the RRB for the amount due.
However, if the RRB is not reimbursed in full at the time
of settlement, you may have to repay benefits to the RRB.

Verify the accuracy of the amount of benefits withheld
from your settlement by checking your own record of
RRB payments or by contacting the RRB. Notify the RRB
immediately if you believe the correct amount was not
withheld from your settlement.

Reconsideration and Waiver
Employee Rlgh1s
Reconsideration - If you do not agree with any decision
denying you benefits or with an overpayment decision,
you may request reconsideration. Your request must be
in writing and should explain why you disagree. If you
request reconsideration, your request must be received at
an office of the RRB within 60 days of the date of the
letter notifying you of the adverse decision. Be sure to
sign your name and include your social security number
on your request.

for an on-duty injury, are considered income for Federal
income tax purposes. Each year, the RRB sends railroad
employees Form W-2, Wage and Tax Statement, showing
the amount of sickness benefits paid during the preceding
calendar year. The amount shown on Form W-2 is the
amount of benefits payable before deduction of Tier I rail­
road retirement tax. The amount includes benefits payable
but withheld to offset a debt to the RRB. A Form W-2 is not
issued if all benefits paid to an employee were for an on-the­
job injury. A Form W-2 is also not issued if all benefits paid
to an employee in a tax year are repaid in the same year.
You may file Form W-4s, Voluntary Tax Withholding, with the
nearest RRB office if you want the RRB to withhold Federal
income tax from your benefits. To change or end withholding
you must file another Form W-4s with the RRB. Form W-4s is
available upon request from the Internal Revenue Service.
The Railroad Unemployment Insurance Act specifically
exempts railroad sickness benefits from State income taxes.

Waiver - You may request waiver of recovery of your
overpayment only if ALL of the following conditions
are met:
1. The amount of the overpayment is more than 10
times the current maximum daily benefit rate;
2. you were not at fault in causing the overpayment;

and
3. recovery would cause you financial hardship to the
extent that you would not be able to meet your
ordinary and necessary living expenses or recovery
would be unfair for some other reason.
If your request for waiver is received at an office of the
RRB within 60 days from the date of the letter notifying
you of your debt, we will not recover the overpayment
until a decision is made on your request.

Employer Rlgh1s
The Railroad Unemployment Insurance Act requires the
RRB to notify your base year employer(s) each time you
file a claim for benefits, and to give the employer(s) an
opportunity to submit information relevant to your claim
before the RRB makes an initial determination on the
claim. The RRB must also notify your employer each time
benefits are paid to you. Your employer may appeal the
decision to pay benefits. The appeal does not prevent the
timely payment of benefits. However, you may be
required to repay benefits if the appeal is successful.

When Sickness Benefits are Taxable

Instructions for Comple1ing Forms
Generallnstrucflons
Complete all items by printing neatly in ink or by
using a typewriter. Do not skip any items unless
directed to do so. If you need more space to answer a
question, enclose a separate sheet of paper. Be sure to

sign your name and date the form before mailing.
Have your doctor complete Form SI-lb, Statement of
Sickness. Do not separate the forms 51-la and 51-lb.
Read the following instructions carefully before completing
your SI-la app1icati.on. If your application is not completed
correctly, your benefits may be delayed. Contact your local
RRB office if you have questions or need assistance in
completing the form. If you are completing the applica­
tion for the employee, refer to page 8 for instructions on
completing Form 51-10, Statement ofAuthOrity to Act for

Employee.

Important Informaflon
The completed and signed form must be received by an RRB
office within 10 days of the first day for which you want to
claim benefits. You may lose benefits if your application is
filed late. If the form is late, enclose an explanation.
Once your application has been processed, a claim form
will be mailed to you for completion. You must complete
and return the claim to the address of the RRB office that
appears on the claim. A notice of the claim will be sent to
your employer. A claim for the next 14-day period will
be mailed to you on or about the last day of the period
covered by the claim.

Sickness benefits paid under the Railroad Unemployment

Insurance Act, with the exception of sickness benefits paid

5

Application for Sickness Benefits
(Form SI- 1a)

Driver - Enter the complete name and address of the
driver of the other car or vehicle involved in the accident.
If more than one other vehicle was involved, give infor­
mation for all vehicles on a separate sheet of paper.

SECTION A - Identifying InformaHon
Items 1-6 are self-explanatory.

SECTION B - Infirmity and Employment Information

Insurance Company - Enter the complete name and
address of the insurance company of the owner of the
other vehicle involved in the accident.

Item 7 is self-explanatory.
Item 8-Enter the date you last worked for your last railroad
employer before you became sick and unable to work. For
example, if you last worked on 12/31 and became sick on
1/1, you would enter 12/31 as the date last worked.
Items 9 and 10 are self-explanatory.
Item 11 - Enter the title of your job. For example, "Road
Brakeman."
Item 12 - Enter the department of the railroad in which
you work. For example, "Train and Engine Service."
Item 13 A-C - Complete this item if you worked for a non­
railroad employer or were self-employed after the last day
you worked for a railroad employer.
• Item 13A Enter the name of the company for which
you worked most recently. For example, "Acme
Accounting."
• Item 13B - Enter the title of your job. For example,
"Accountant."
• Item 13C - Enter the date you last worked outside
the railroad industry before you became sick and
unable to work. For example, if you last worked on
12/31 and became sick on 1/1, you would enter 12/31
as the date last worked.

SECTION C - Accident and Insurance Information
Items 14 is self-explanatory.
Item 15 - Check ''Yes'' if you med or expect to me a lawsuit or
claim against any person or company for personal injury.
Items 15A is self-explanatory.
Item 15B - Enter the location where your injury or illness
occurred. Forexample, "Hwy 51/County Rd 12, Toledo, Ohio."
Item 15C - Check "Yes" if you were injured in a automobile
accident.
Item 15D - If you checked "Yes" in Item 15C, complete
the following items about all the vehicles involved in the
accident, other than your own.
Owner of Car - Enter the complete name and address of.
the owner of the other vehicle involved in the accident.

6

Policy Information - Enter the policy number of the insurance
policy held by the owner of the other vehicle and the claim
number assigned by the insurance company, if you know it.

SECTION D - Claim for Sickness Benefits InforrnaHon
Your first sickness benefit claim is Items 16 through 20 on
your 51-la, Application for Sickness Benefits. After your
application and claim have been received and processed,
your next sickness claim will be mailed to you.

Item 16 is self-explanatory.
Item 17 - Check "Yes" if you want to claim every day
from the date you entered in Item 16 through the current
date as a day of sickness. Check "No" if you do not wish
to claim every day. Remember that you cannot claim
benefits for any day on which you worked or otherwise
earned wages, holiday pay, vacation pay, sick pay
(excluding supplemental sickness benefits) or other pay.
This includes pay from full-time and part-time work in
either railroad or nonrailroad employment, and from
self-employment. You may claim rest days on which you
were sick or injured and for which you do not receive
pay from your employer.
Item 18 - If you checked "No" in Item 17, enter the dates
that you do not wish to claim.
Item 19 - If you have recovered from your infirmity and
have returned to work, enter the date you returned to
work. However, if you worked one or more days, but
then continued to be unable to work, do not enter a date
in this item. For example, if you attempted to return to
work but found that you were not able to continue work­
ing, indicate the days you worked and received wages in
Item 18, but do not enter a date in Item 19.
Item 20A-C - Each item must be checked "Yes" or "No"
to indicate the type of payments, if any, that you have
received or will receive for days in the claim period.
Also furnish the dates and/ or other information request­
ed about the payment. The types of payments are
explained below.
Item 20A - Wages - Payments that you receive from your
railroad employer, from a nonrailroad employer or your
own business for services you performed. Benefits are not
payable for any day for which you receive wages.

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039

Application for Sickness Benefits
Section A

Identifying Information

1. Employee's Name (First, Middle Initial, and Last)

2. Social Security Number

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

I--:-:----=-,---=---r---:-:Y:-"ea-r----l

Section B

5. Sex

0

Male

o Female

Infirmity and Employment Information

7. Date You Became Sick or Injured _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

8.

Date You Last Worked for a Railroatiu._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

9.

Last Railroad Employer (Name of Company) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

io. Location of Last Railroad Employment
11. Last Railroad vvvU}JaUvll._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
12. Department _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
13. Ifyou worked for a nonrailroad employer after the date showu in Item 8, complete Items A, B, and C, below. Otherwise, go to Item 14.
A. Last Nonrailroad Employer (Name o f C o m p a n y ) - - - - - - - - - - - - - - - - - - - - - - - - - ­
B. Last Occupation After Railroad W o r k - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ­

C. Date Last Worked After Railroad Work

Section C

Accident and Insurance Information

14. Are you applying for sickness benefits because you were injured at work or have a work-related illness? 0 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
0 No - Go to Item 16
A. Furnish the name and complete address of the person or company.

0

No

o

Name-----------------------------------------­
Ad~ess-------------------~--------------------

City, State, ZIP C o d e - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ­
B. Give the place where the injury occurred. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ­

C. Were you injured in an automobile accident?

DYes

o No - Go to Item 16

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 space attach a separate sheet of paper.

Owner of Car other vehicle)

Driver (other vehicle

Name

Name

Ad~s

Address

City, State, ZIP Code

City, State, ZIP Code

Insurance Company (other vehicle)

Policy Information (other vehicle)

Name

Policy Number

Address

Claim Number

City, State, ZIP Code
Continued on Reverse Side

SI-la (02-09)

Section 0

Claim for Sickness Benefits Information

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 l6? (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 Jl1.lW complete all boxes to indicate ifyou have received or will receive any ofthe following payments for your days ofsickness.
If you check "YES" for any item, be sure to provide the requested information.
A. WAGES (Include Railroad and Nonrailroad Wages)

YES NQ If "YES," show the dates for which you were paid in MonthlDaylYear format below.

0 Regular Wages................. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Vacation Pay .................. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Holiday Pay .................. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Military Reservist Pay .......... _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Wage Continuation Pay ......... _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Earnings from Self-Employment .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
0 Sick Pay from Your Employer .... --::---:-=---:c---::::---:-:::::-,.-~,_____=-=___=_____:_-=__,__:_:__----­
(but not payments supplementing Railroad Retirement Board (RRB) benefits. See Booklet UB-II)

o
o
o
o

o
o
o

B. GOVERNMENTAL PAYMENTS (Not RRB Sickness Benefits)

YES NO If "YES," enclose copy of award letter and complete Items 1 - 3 below.

0 Sickness or Unemployment Benefits Under Any Other Law
1. Beginning Date of Payment _ _ _ _ _ _ __
0 Social Security Benefits
2. Gross Amount of Payment $
0 Railroad Retirement or Disability Annuity
3. How often do you receive the-p-a-y-m-e-nt-?---­
0 Military Retirement Pay
0 WeekI 0 Monthl 0 Year!
y
y
0 Worker's CompensatIOn
D 'y
0 Retirement Payments Under Another Law
Other. - - - - - - - - - - - - - ­

o
o
o
o
o

o

C. OTHER PAYMENTS

YES NO If "YES," complete Items 1 and 2.

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

o
o
o

1. Date of Payment
2. Paid By: _ _ _ _ _ _ _ _ _ _ _ __

21. Ifthe 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.

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.
TITLE

Section E

Direct Deposit Information

22. 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
fmancial institution for the information you need to complete Items A-E. If you do not have a bank account, or receiving your pay­
ments by Direct Deposit would cause you a
. go to Item F.
A. Routing Transit Number

D. Name of Financial Institution: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

C. Account Type:

o Checking
F.

0

B. Account No. _ _ _ _ _ _ _ _ _ _ _ __

0

Saving

E. Telephone No. (Include Area Code) '--_ _-'_ _ _ _ _ _ _ _ _ _ __

Check this box if you do not have a checkin , or savings account, or if Direct De osit would cause you a hardship.

Section F

Certification and Signature

23. I waive any "doctor-patient privilege" 1 may have with respect to the disclosure ofinformation 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-II. 1know that disqualification and civil and
criminal penalties may be imposed on me for false or fraudulent statements or claims or fur withholding information to get benefits from the

RRB. I affirm that the information given on this form is true, correct and complete. NOTE: Ifthe sick or injured employee is unable to sign
this form, sign your name and complete Section 1 ofthe attached Form SI-1 0, Statement ofAuthority to Act for Employee.

SIGNATURE
SI-l a (02-09)

HAVE YOUR DOCTOR COMPLETE THE AITACHED STATEMENT OF SICKNESS

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039

Statement of Sickness

Instructions:

This form is to be executed by (1) a doctor trained in medical, surgical, dental or psychological diagnosis of
the infirmity described, (2) a certified nurse/midwife in cases of pregnancy or childbirth, (3) a supervisory official of a
hospital or similar institution, (4) a chiropractor, (5) a Physician Assistant - Certified, or (6) a nurse practitioner. This form
should be completed and returned to the patient immediately for prompt mailing; otherwise he/she may lose benefits.
Supplementary medical information may be attached or furnished directly to the Railroad Retirement Board (RRB) at the
address shown below. If such information is furnished, please include the patient's social security number and name on the
report. Please complete section 2 on the reverse side if patient is incapable of signing forms.

The RRB is not liable for any charge in connection with completing this form.

1. Patient's Name (First, Middle, and Last)

2. Patient's Social Security Number

3. Have you examined or treated the patient for his or her injury or illness?

a.

0

Yes

0

No

Go to Item 9

b. List ali dates of examination and treatment for this infirmity

Date patient became sick or injured

C. Probable date of next examination

4. Diagnosis and concurrent conditions

5. Does the patient's condition require surgery?

a.

0

Yes

0

6
b. Surgical procedure that was or will be performed

No - Go to Item

Date on which surgery was or will be performed

6. Does the patient's condition require hospitalization?
DYes - Enterthe period of hospital confinement: From _ _ _ _ _ _ _ _ _ _ To _ _ _ _ _ _ _ _ __

o

No

7. If patient is not working because of maternity or childbirth, complete 7a and 7b.
a. Date
became unable to work ..
b. Estimated or actual date of
8. Give the date you believe the patient became or will become able to resume work in his or her occupation.
(If indefinite or unknown, please give an estimated date.) ..
9. I certify that the information I am giving is true, complete, and correct. I understand that criminal and civil penalties may be imposed
on me for false or fraudulent statements or for withholding information to cause or prevent payment of benefits by the RRB.

Please print or type:

Name of Doctor

Signature of Doctor

Degree/Title

Address

Office Telephone Number (Include Area Code)

Date

(

)

National Provider Identifier

PAPERWORK REDUCTION ACT NOnCE TO DOCTOR
Medical evidence is needed to support the payment of claims for sickness benefits underlhe Railroad Unemployment Insurance Act (RUIA). The RRB is
authorized to collect this information under section 12(i) of the RUIA. You are not required to furnish this information. If you do not, however, no benefits
can be paid to your patient. We estimate this form and the form on the back of this page take an average of 8 and 6 minutes to complete, respectively.
The estimates include the time for reviewing the instructions, getting the needed data, and reviewing the completed forms. Federal agencies may not
conduct or sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB number. If you wish, send
comments regarding the accuracy of our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Chief of
Information Resources Management, Railroad Retirement Board, 844 N Rush Street, Chicago, Illinois, 60611-2092. Send completed forms to:

U.S. RAILROAD RETIREMENT BOARD

OFFICE OF PROGRAMS-OPERATIONS

POST OFFICE BOX 10695

CHICAGO, ILLINOIS 60610-0695

Doctor: See Reverse Side

FORM SI-1b (06-09)

United States of America
Railroad Retirement Board

Form approved
OMB No. 3220-0034

Statement Of Authority To Act For Employee

It is not necessary to complete this form for an employee who can sign papers or can
sign by mark and understands transactions relating to his or her sickness benefits.

Instructions
1. Complete Section 1 and have the employee's medical doctor complete Section 2. If you are not related to the employ­
ee by blood or marriage, state your relationship and explain why no relative is acting for the employee. For exam­
ple, an employee's union representative might explain: "I am his union chairman. He has no immediate family."
2. Complete this statement by following the instructions in the UB-II booklet under "Instructions for
Completing Forms, Statement of Authority to Act for Employee (SI-1O)." Signing this statement gives you the
authority to sign any claim forms on behalf of the employee. When signing claim forms use your full name,
and beneath your signature, write "On behalf of" and the employee's full name.
3. Return this form with the next application or claim form you file with the RRB.

Section 1

Statement of Individual Acting for Employee

It is my belief that
(Employee's Name)

w hose address is

(Social Security Number)
(Employee's AaarE!SS)

is at this time incapable of signing forms in connection with obtaining sickness benefits under the Railroad
Unemployment Insurance Act; of transacting the necessary business relative to his or her application and claims
for such benefits; and of applying the proceeds of any sickness benefit payments.
I believe the employee to be incapable because ___________________________

(Briefly describe employee's condition)

My relationship to the employee is ______________________________
I affirm that, in the transaction of business relating to the application and claims of this employee, including the use
of any benefit payments, I will act on behalf of and in the best interest of the employee. I will promptly notify the
RRB at such time as this employee's condition changes so that I need no longer act for him or her. I understand that
criminal and civil penalties may be imposed on me for providing false, incomplete, or fraudulent statements; using
the benefits received on something other than the claimant; or for withholding information to cause the payment of
benefits. I certify that, to the best of my knowledge, the information I have provided is true, complete, and correct.
Name (please print)

Signature

Phone Number
(

Street Address (please print)

Section 2

City

)

State ZIP Code Date

Statement of Employee's Doctor

I have examined the employee named above and find that he/she. is incapable of signing forms and transacting
business relative to his/her claims for sickness benefits under the Railroad Unemployment Insurance Act.
Signature of Doctor

Name of Doctor (please print)
Office Street Address (please print)
iNational Provider Identifier

SI-10 (06-09)

City

State ZIP Code Date

Regular Wages - Pay for time worked, including full­
time and part-time work.

Worker's Compensation - Disability payments
made to you under a state law when you have
been injured on the job.

Vacation Pay - Pay for scheduled or assigned vaca­
tion days. Vacation pay does not include "pay in lieu
of vacation." If you do not know if the payment you
received was "pay in lieu of vacation," check with
your payroll office before completing this item.

Retirement Payments Under Another Law - An
annuity or pension paid to you by a county, city,
state or the Federal Government.

Holiday Pay - Pay from your employer for a holiday.

Military Reservist Pay - Wages paid to you by the
Federal Government based on your military service.
Wage Continuation Pay - Salary or wages paid by
your railroad employer when you have been injured
on-duty. The purpose of the payments is to continue
your wage or salary, not to supplement RRB benefits.
The payments are subject to normal payroll deduc­
tions.
Earnings from Self-Employment - Pay for services
performed.
Sick Pay from Your Employer - A continuation of
all or part of your wages while you are unable to
work. The term "Sick Pay" does not include supple­
mental sickness benefits. For an explanation of sup­
plemental sickness benefits, see page 4.
Item 20B - Governmental Payments - Annuities or other
payments made to you by a county, city, state or the
Federal Government. If you are receiving a governmental
payment, check the appropriate box and enter the begin­
ning date, the gross amount and the frequency of the
payment. For an explanation of how governmental pay­
ments affect the payment of sickness benefits by the RRB,
see the section Benefit Reductions on page 4 .
Sickness or Unemployment Benefits Under Any
Other Law - Benefits paid to you on account of sick­
ness or unemployment by a county, city or state gov­
ernment, or by another Federal agency.

Social Security Benefits - Benefits paid to you by the
Social Security Administration, excluding supple­
mental security income payments (SS1).
Railroad Retirement or Disability Annuity ­
Monthly payments made to you by the RRB
based on your age and railroad service or on dis­
ability. An RRB annuity under the Railroad
Retirement Act is not the same as RRB sickness
benefits.

Military Retirement Pay - An annuity, pension or
retainer pay paid to you by the Federal Government
based on your military service.

Item 20C - Other Payments - If you are receiving some type
of other payment, check the appropriate box and give the
date of the payment and who made the payment to you.
Settlement or Damages for Personal Injury - A pay­
ment received as a result of a judgment or the settle­
ment of a personal-injury claim against your railroad
employer or another party that you held liable for
your injury or illness.
Advances - A payment received in anticipation of a
settlement of a personal injury claim against your
railroad employer.
Separation Allowance (Buyout, Severance Pay) - A
payment received when you resign in return for a
specified sum of money. The payments are also
referred to as "buyouts" or "severance pay."
Payment may be made in a lump sum or installments
in return for your resignation.

Item 21 is self-explanatory.

SEcnON E - Direct Deposit InforrnaHon
Item 22 - Federal law requires the RRB to pay your
benefits by Direct Deposit. With Direct Deposit, your
benefit payments are sent directly to your bank, savings
and loan, credit union or other financial institution.
Payments are sent electronically, which saves money by
eliminating the need to print and mail checks.

Direct Deposit has many advantages. Direct Deposit
payments are generally available 2 to 5 days sooner than
payment by check. You do not have to worry about a
check being lost, stolen, or misplaced, and you can be
away from home without the worry of a check sitting
unprotected in your mailbox. There is no need to wait
for mail delivery of a check or to make a special trip to
your bank.
To provide the information we need to correctly deposit
your benefit payments, attach a voided personal check to
your application. If you do not attach a voided personal
check, call your financial institution for the information
you need to complete Item 22A-E.
If you change banks or accounts while claiming benefits,
be sure to give the RRB information to establish Direct
Deposit to your new account. Do not close your old
account until you receive the first RRB payment in your
new account.

7

There are some exceptions that allow payments to be
made by check:

Completing Form 51-10, gives the signer the authority to
sign any claim form on behalf of the employee.

• If receiving your payments by Direct Deposit would
cause a hardship because you have a physical or
mental disability, or because of a geographic, language,
or literacy barrier; or

SECTION 1- Statement of Individual Acting for
Employee

• if you do not have a checking or savings account at a
bank or other financial institution; or
• if receiving your payments electronically would cause

you a financial hardship because it would cost you
more than receiving your payments by check.
If any of these apply to you, check the box in Item 22F.

SECTION F - CerHflcatfon and Signature
Item 23 - By signing and dating this item you certify that
the information contained on the form is true, correct,
and complete.

This section is to be completed by the individual who
signed the 5I-la, Application for Sickness Benefits, and who
will act on behalf of the employee. Enter the employee's
name, social security number, and address. Briefly explain
why you believe the employee is incapable, and enter your
relationship to the employee. If you are not related to the
employee by blood or marriage, state your relationship
and explain why no relative is acting for the employee.
For example, an employee's foreman might explain: "My
relationship to the employee is his foreman. He has no
immediate family."
When signing claim forms use your full name, and
beneath your signature write "On behalf of" and the
employee's full name.

SEGnON 2 - statement of Employee's Doctor
If the sick or injured employee is unable to sign in Item 23,
the person completing the application should sign in
Item 23, and complete Form 5I-lO, Statement of Authority

Have the employee's medical doctor complete this
section.

to Act for Employee.

Claim for Sickness Benefits

Statement of Sickness (Form SI-1 b)

(Form SI-3)

The 5I-lb, Statement of Sickness, must be completed by
your doctor or other qualified medical provider (see the
section Medical Statements on page 3). If possible, have
your doctor complete the statement while you are at the
office, rather than leaving the form for completion. If you
must leave the form for completion, explain to your
doctor that the form is needed for you to receive bi­
weekly benefit payments and that the form must be
received by the Railroad Retirement Board within 10
days of the first day you became sick or injured or you
may lose benefits.

The following instructions are for claim forms maned to
you by the RRB. Read the instructions carefully before

Do not separate the SI-lb, Statement of Sickness, from
your 51-la, Application for Sickness Benefits.

Statement of Authority to Act for
Employee (Form SI-1 0)
Completion of Form 51-10, Statement of Authority to
Act for Employee, is not required for an employee
who can sign papers or can sign by a mark and who
understands transactions related to his or her application
for benefits.

8

completing your claim forms. Failure to complete your
claim correctly could delay the payment of benefits.
IMPORTANT INFORMATION

Claims for days after your first claim, which is included
on the 5I-la, Application for Sickness Benefits, will be
mailed to you for as long as you remain unable to work
and eligible for benefits. You must complete and return
each claim promptly or you may lose benefits. The time
for filing a claim, including time for mailing, is limited to
30 days from the last day of the claim period, or 30 days
from the date the claim form was mailed to you, whichev­
er is later.
If you return to work and stop claiming benefits, but
become sick or injured again later in a benefit year, you
must file a new 51-la, Application for Sickness Bene6.ts.

RAILROAD RETIREMENT BOARD

FORM APPROVED OMB 3220-0039

ClAIM FOR SICKNESS BENEFITS
1111111111111111111111111111111111111111111111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIili
090 1 12808 112908

120208

J SMITH

02 02 700

123-45-6789

1 . This claim is for sickness benefits for the period shown below. To claim benefits, mark the box under each date with the
appropriate code (X. E, p, or 0).
X - Claimed day of sickness
(Including rest days)

P - Vacation, holiday, sick pay, or other pay from your employer
(Do not report supplemental sickness benefits)

E Day employed (Include railroad. non·
railroad, or self-employment)

0- Day not claimed, other reason

This claim is for
11-21-08 through 12-04-08
Mark each box with X, E, P, or 0

----.

Item 1 - This item shows the days in the claim period.
Below each day of the claim period, you must enter the
correct letter code to show whether you want to claim
benefits for the day; or whether you worked, received
vacation pay, holiday pay, or other pay from your
employer; or that you do not want to claim benefits for
some other reason.
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 supple­
mental sickness benefits), or other pay. This includes
pay from full-time and part-time work in either railroad
or nonrailroad employment.
Use the following letter codes to show whether you are
claiming benefits for the days in the claim period:

x - Enter an ''}(!' if you did not work on the day, will
not receive any type of pay for the day, and were
unable to work because of injury or illness on the day.
Any day you mark with an ''}(!' is considered to be a
day of sickness for which you are claiming benefits.
Use an "X" to claim normal rest days on which you
were unable to work. Do not claim your rest days if
you were able to work, worked, or otherwise
received pay from either a railroad or nonrailroad
employer for the days.
E - Enter an liE" if you were employed either full
time or part time on the day. Include work for
either a railroad or nonrallroad employer, and any
self-employment.
P - Enter a "P" for any day that you were not
employed, but will receive payment from a railroad

26

27

28

29

30

x

X

X

X

X

E

2

3

4

E

0

0

or nonrailroad employer. This includes such pay­
ments as vacation pay, holiday pay, wage continua­
tion pay, sick pay (excluding supplemental sickness
benefits), daily wage guarantee payments, and pay
for time lost.
Do not enter "P" for days you receive payments
under a supplemental sickness benefit plan paid or
financed by your employer, such as benefits paid by
Trustmark Insurance Company or Provident Life
Insurance Company. Such payments are normally
paid in addition to your sickness benefits from the
RRB. For an explanation of the difference between
regular sick pay, which you must report, and supple­
mental sickness benefits, see the back of your claim
form or the section Sick Pay and Supplemental
Sickness Benefits on page 4 of this booklet.

0- Enter an "0" for days on which you did not work
and did not receive any type of payment, but which
you do not wish to claim for some other reason.

An example of how the boxes are to be completed is
shown above.
Item 2A * If you have recovered from your infirmity and
have returned to work, answer Item 2A "Yes" and enter
the date you returned to work in Item 2B. If you attempted
to return to work but found that you were not able to
continue workin& answer Item 2A "No" and enter an
"E" in Item 1 for any day you worked and received
wages. Do not enter a return-to-work date in Item 2B.

Item 3

This item is prefilled with the name and
address of your local RRB office. Mail your completed
claim to that office.
*

9

Item 4 - This item is prefilled with your name and
address. If necessary, show corrections to your name and
address in the box.
Item 5A-C - See Item 20A-C on page 6 of this booklet for
instructions on completing Item 5A-C. Reference Item
20A to complete Item 5A; Item 20B to complete Item 5B;
and Item 20C to complete Item 5C.
Item 6 - By signing and dating this item you certify that
the information contained on your claim form is true and
complete. Do not complete and sign the claim form
before the last day of the claim period. If your claim is
mailed to the RRB before the last day of the claim period,
benefits due you may be delayed or denied.

Pl1vacy Act Noflce
To receive sickness benefits you must apply for them
and furnish information. Information that the RRB asks
you to furnish is used to determine if you are eligible for
benefits and the amount of benefits payable to you.
Although furnishing information, including your social
security number, is voluntary, the RRB cannot pay you
benefits without this information. The RRB's authority
for requesting information is Section 5(b) of the Railroad
Unemployment Insurance Act.
The RRB may routinely furnish information to the follow­
ing individuals, organizations, and/or agencies for the
purpose of administering the Railroad Unemployment
Insurance Act, the Social Security Act, or other benefit
programs under Federal or State laws:
1. The U. S. Treasury Department and the U.S. Postal
Service, to issue benefit payments and to report non­
delivery, forgery, theft or loss of a benefit payment.

2. A person or company which the claimant reports may
award pay for time lost or some similar payment for the
same period for which the RRB pays benefits.
3. Persons or companies named by the claimant as liable
for paying damages for the same injury or illness for
which the RRB pays sickness benefits.
4. The Internal Revenue Service for use in administering
Federal tax laws.
5. A private collection agency, the General Accounting
Office, the Department of Justice, or the Internal Revenue
Service for the collection of an overpayment.
6. Employers or insurance companies for use in adminis­
tering supplemental benefit or health insurance plans.

10

7. Law enforcement agencies and the Department of
Justice for investigating or prosecuting a violation of law
8. Employers to verify entitlement to benefits and to
provide notice of benefit payment determinations.
9. State unemployment agencies to verify entitlement to
benefits.
Other than information that may be disclosed routine­
ly, no information about your claim may be disclosed
without your consen~.

Computer Matching and Pl1vacy

Protection Act Notice

In addition to the uses of information described in the
preceding Privacy Act Notice, information you provide
may be used, without your consent, in automated
matching programs. These matching programs are a
computer comparison of Railroad Retirement Board
records with records kept by other Federal agencies or
State and local governmental agencies. Information
from these matching programs can be used to establish
or verify a person's eligibility for benefits and for
repayment of benefits or delinquent debts.

What Are Computer Matching Programs?
Computer matching programs compare our records with
those of other Federal, State, or local government agen­
cies. All agencies may use matching programs to find or
prove that a person qualifies for benefits paid for by the
Federal Government.

How Do Computer Matching Programs Affect
You?
On forms that you fill out for us you give us facts about
yourself. Sometimes, we check the facts you and others
give us. We use computer matching to do the checking.
The law allows us to check this way even if you do not
agree to it. We can also give any facts we have about you
to other governmental agencies for them to use in their
computer matching programs.

Paperwork. Reduction Act Notice
To receive sickness benefits, you must complete an
application and claim form(s). You may also be asked to
complete other forms. Some of these forms are listed
below along with estimates of how long we think it takes
to complete them. The estimates include time for reviewing
the instructions, getting the needed information, and
reviewing tlle completed fonn. Federal agencies may not
conduct or sponsor, and respondents are not required to
respond to, a collection of information unless it displays a
valid OMB number. If you wish, send comments regarding
the accuracy of our estimates or other aspect of the forms,
including suggestions for reducing completion time, to the
Chief of Information Resources Management, Railroad
Retirement Board, 844 N. Rush Street, Chicago llIinois
60611-2092. Be sure to include the form title and control
number (in parentheses) with your comments.

Estimated
Completion
Form
No.

Title

Time
(Minutes)

SI-la

Application for Sickness
Benefits (3220-0039)

10

SI-1b

Statement of Sickness
(3220-0039)

8

SI-3

Oairn for Sickness
Benefits (3220-0039)

5

fJ,/~AlGT ti.-fl-tNl. P-;),L

Nondlscr1mlnaNon on the

Basis 01 Dlsablltty

Under Section 504 of tlle Rehabilitation Act of 1973 and
RRB regulations, no qualified person may be discriminated
against on the basis of disability. RRB programs and
activities must be accessible to all qualified applicants
and beneficiaries, including those who are vision- or
hearing-impaired. Disabled persons needing assistance
(including auxiliary aids or program information in
accessible formats) should contact the nearest RRB office.
Complaints of alleged discrimination by the RRB on the
basis of disability must be filed within 90 days in writing
with the Director of Administration, Railroad Retirement
Board, 844 North Rush Street, Chicago, illinois 60611-2092.
Questions about individual rights under this regulation
may be directed to the RRB's Director of Equal Opportunity
at the same address.

os: IL/"-Nc 5.<;.

SI-10

Statement of Authority
to Act for Employee
(3220-0034)

6

ID-7h

Notice of Non-Entitlement
to Sickness Benefits and
Information on
Unemployment Benefits
(3220-0039)

5

·~GAlc:;:t=..:z:rs (3 Z"LO- 00 5'1')

11

Checking Your Benefits by Telephone

You can obtain detailed information about your
sickness benefit payments and claims at any
time, by calling our national automated tele­
phone service. Calling this number gives you
access to:
• the amount and date of your latest benefit
payment, and the claim period for which the
payment was made;
• information about your last 5 benefit payments;
and
• confirmation of whether we have received
your latest claim, application or supplemental
doctor's statement.
We update payment information once each
night; we update information about applications,
claims, and supplemental doctor's statements as
we receive the forms.

To access your benefit information by telephone:
• Call the Railroad Retirement Board at
877-772-5772 .
• Press "l" to select our automated HelpLine
services.
• Press "1" again to access the Sickness
Benefits Menu.
lSlQte: People who are deaf or hard of hearing

may call our TTY number at 312-751-4701.
You will need your social security number and
your Personal Identification Number (PIN) to
get information about your benefit payments
and claims. Your PIN is printed on the back of
each claim form we mail to you.

Each claim you receive will have a record of your last 3 payments. Use the HelpLine services and the tables
below to keep track of your claims and payments.
Please allow at least 15 days from the date you mail your claim to receive a payment. That time is needed for
delivery of your claim and payment, and to allow your employer to submit information about your claim.

Record of

Record of

Claims Submitted

Payments Received

:

Beginning Date
Number of
Days Claimed
of Claim

12

Date Mailed
toRRB

Amount of
Payment

Date Payment
Received

Important Reminders

Filing Requirements - To avoid losing sickness ben­
efits, your benefit application must be received by a
Railroad Retirement Board (RRB) office within 10
days of the first day for which you want to claim
benefits. Your sickness claims must be filed within 30
days of the last day of the claim or 30 days from the
date we mail the form to you, whichever is later.
Benefit YearfBase Year-A new benefit year begins
each July 1. Eligibility for benefits in a benefit year is
based on your earnings in the previous calendar year
(base year). For an example, see section titled
Qualification Requirements.
Waiting Period Requirement- To satisfy a one-week
waiting period requirement, no benefits are payable
for your first 7 days of sickness in your first claim in a
period of continuing sickness, unless you have
already served a waiting period in the benefit year.

Even though no benefits are payable for the first 7
days of sickness, you must file a claim for your
days of sickness during the waiting period; other­
wise you may lose benefits for claims after the
waiting period.
Do Not Claim Benefits for Days You Work or
Receive Pay - Benefits are not payable for any day
for which you receive pay. This includes wages from
military reservist duty, full- or part-time work for a
railroad, non-railroad employer, or self-employ­
ment. It also includes vacation pay, holiday pay, pay
for time lost, guarantee pay and other types of
remuneration.
Reconsideration Rights- You may request recon­
sideration of any decision denying you benefits. A
request for reconsideration must be made in writing
within 60 days of the date of notice of the Railroad
Retirement Board's adverse decision.

Fraud and Abuse Hot Line
Call the toll-free Hot Line if you have reason to
believe that someone is receiving railroad unem­
ployment or sickness benefits to which he or she is
not entitled. The Hot Line has been installed by the
Railroad Retirement Board's Inspector General to
receive any evidence of fraud or abuse of the RRB's
benefit programs.

The toll-free Hot Line number is 1-800-772-4258. Or
you may send your complaints in writing to: RRB,
OIG, Hot Line Officer, 844 North Rush Street,
Chicago, Illinois 60611-2092. Please do not call the
Inspector General's Hot Line with questions about
eligibility requirements, delayed claims, or similar
problems. Such matters should be directed to the
nearest Railroad Retirement Board field office.

Old You Know...

Railroad employees do not pay for their sick­
ness benefits protection. The funds come from a
payroll tax on employers.
A fine, jail sentence, and disqualification
may be imposed upon any person found to
have withheld information or to have made
false or fraudulent statements or claims for
the purpose of causing benefits to be paid.

We encourage you to file certain proofs in
advance of retirement-age, military service~
and marriage. If married, you should also
submit proof of your spouse's age. We record
and store the information electronically until
your retirement. Filing proofs in advance
speeds the application process and helps avoid
any delay in processing that could occur due
to inadequate or missing proofs.

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