Railroad Unemployment Insurance Act Applications

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0039 can be found here:

Documents and Forms

Document Name Document Type
Form SI-1a (02-01) Railroad Unemployment Insurance Act Applications Form
SI-1a (02-01) Application for Sickness Benefits SI-1a (02-01).pdf www.rrb.gov/pdf/PandS/ub11.pdf Form
SI-3 (07-04) Claim for Sickness Benefits SI-3 (07-04).pdf Form
ID-7H (09-99) Non-Entitlement to Sickness Benefits and Information on Form ID-7H (09-99).pdf Form and Instruction
ID-11A (07-07) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (current).pdf Form and Instruction
ID-11B (07-07) Notice of Insufficient Medical and Late Filing Form ID-11B (current).pdf Form and Instruction
SI-3 (Internet)(pr Claim for Sickness Benefits SI-3 (Internet)(proposed) .pdf Form and Instruction
UB-11 (06-09).pdf UB-11, Sickness Benefits for Railroad Employees IC Document
Form UB-11 (proposed).pdf UB-11, Sickness Benefits for Railroad Employees IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Railroad Unemployment Insurance Act Applications	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 335

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SI-1a (02-01)	Application for Sickness Benefits	SI-1a (02-01).pdf	http://www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only
Form	SI-3 (07-04)	Claim for Sickness Benefits	SI-3 (07-04).pdf		No		Paper Only
Form and Instruction	ID-7H (09-99)	Non-Entitlement to Sickness Benefits and Information on Unemployment Insurance Benefits	Form ID-7H (09-99).pdf		No		Paper Only
Form and Instruction	ID-11A (07-07)	Requesting Reason for Late Filing of Sickness Benefit	Form ID-11A (current).pdf		No		Paper Only
Form and Instruction	ID-11B (07-07)	Notice of Insufficient Medical and Late Filing	Form ID-11B (current).pdf		No		Paper Only
Form and Instruction	SI-3 (Internet)(proposed)	Claim for Sickness Benefits	SI-3 (Internet)(proposed) .pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records
Title: RRB-21-Railroad Unemployment and Sickness Insurance Benefit System	FR Citation: 40 FR 36275

Number of Respondents: 17,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	157,850	20,850	-32,050	169,050
Annual IC Time Burden (Hours)	14,541	1,738	-3,104	15,907
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees	UB-11 (06-09).pdf	07/26/2010
UB-11, Sickness Benefits for Railroad Employees	Form UB-11 (proposed).pdf	07/26/2010

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