BA-12 (05-09) Application for Employer Reporting Internet Access

Form Approved
OMB No. 3220-0008

United States of America
Railroad Retirement Board

Application for Employer Reporting Internet Access
General Instructions–This form may be used by employers covered under the Railroad Retirement and Railroad
Unemployment Insurance Acts to add, modify, or terminate employee access to the Railroad Retirement Board’s (RRB)
Internet employer reporting site. You may request system access for one or more employees, and you may authorize
different levels of access for each employee. You may also request that an individual employee file online reports on
behalf of one or more subsidiary or affiliate employers. In each case, your employees must certify that they will adhere to
the RRB’s security guidelines, which include use of an authoritative electronic signature. The Security Guidelines are on
the RRB’s web site at www.rrb.gov/employer.
To request new or modified system access, complete the entire form. To terminate an employee’s access, complete only
Sections A, B (1-4), C (1), and D.
Making representations on this form to gain unauthorized access to the RRB Employer Reporting System or
using an authorized access for fraudulent purposes is a violation of federal law punishable by fine,
imprisonment, or both.

Section A

Employer Information

In this section, you provide the BA number, name, and address of the employer whose reports will be accessed online.
Special Instructions to Request Access on Behalf of Multiple Employers–If you are requesting the same level of
access for the employee listed in Section B on behalf of multiple employers, list all affected BA numbers in Item 1. If you
are requesting different levels of access for this employee for different employers, file a separate application for each
level of access.
1.

BA Number(s):

2. Name and Address of Employer–If you are requesting access on behalf of multiple employers, provide only the
name and address of the employer serving as primary contact for this account.

Section B
1.

Name:

2.

Title:

Employee Information

3.

Telephone Number:
(

4.

E-Mail Address:

)

5. I have read the document "Security Guidelines" and agree to comply with these guidelines. I understand that my
logon, if used to file forms, has the same status as my signature on a paper document. I also understand that
providing false or fraudulent information through the RRB Employer Reporting System is a violation of federal law
punishable by fine, imprisonment, or both.

Signature: _____________________________________________________

Date: _______________________

Form BA-12 (05-09)

Section C

Requested Action and Level of Access
Add New User

Modify Access

Terminate Access

1.

Action (check appropriate box)

2.

Level of Access (Check the appropriate box. Mark only one box for each form.)
● Form BA-4 - Three levels of online access are available for Form BA-4. Level “R” restricts access to “read only.”
Separate update and supervisory approval steps may be established by restricting an employee to level “U” or
“update” access, as long as another employee is assigned level “A” or “approve” (update, approve, certify, and
submit) access. Level “A” access is also appropriate for any employee who independently updates, certifies, and
submits Form BA-4.
● Forms BA-6a and GL-129a - Level “A” is the only available option.
● Check the box marked “X” to prohibit online access to a particular form.
The level of access you are requesting for the employee listed in Section B above will apply to all employers listed
in Section A.
For additional information on levels of access, see Reporting Instructions to Employers, Part VIII, Chapter 2, or go to
www.rrb.gov/employer and select “Reporting Instructions.”
Form BA-4, Report of Creditable Compensation Adjustments

R

Form BA-6a, Form BA-6 Address Report

U

A

X

A

X

Form GL-129a, Record of Employer Determination on Employee
A
X
Protest of Service and Compensation
Form ID-4E, Notice of RUIA Claim Determinations
Form ID-4K, Prepayment Notice of Employees' Applications and
R
A
X
Claims for Benefits under RUIA
Certification of Authority to Approve Access
Section D
The form must be signed by an official with signature authority to sign RRB forms for the employer(s) listed in Section A.
Signatures of two individuals are not required if the employee listed in Section B has authority to sign RRB forms. The
head of the company and those persons designated on Form G-117A, Designation of Contact Official, have signature
authority. A contact official may assign signature authority to a designee, but the RRB will verify with the contact official
any signatures other than those of a contact official.
1. Name: (print)
2. Title:
3. Telephone Number:
(
)
4.

I have signature authority to approve this request and authorize the RRB to grant access as indicated above. I
understand that I am responsible for notifying the RRB if, in the future, this individual's access should be terminated.
Signature: _____________________________________________________

Section E

Date: _______________________

Group or Section E-Mail Address to Receive Notices

Complete this section only if you prefer to designate a group or section e-mail address as the default address for RRB
work notices, rather than the e-mail address listed in Section B above.
1.
2.

Default E-Mail Address:
If you have more than one group or section e-mail address, number each address and specify here which forms or
group of forms are associated with each address.

Questions?
Please contact the Quality Reporting Service Center at (312) 751-4992.
Mail this completed application to:

Quality Reporting Service Center
Railroad Retirement Board
844 N Rush Street
Chicago, IL 60611-2092

We estimate this form takes an average of 10 to 20 minutes per response to complete, including the time needed for reviewing the instructions,
getting the needed data, and reviewing the completed form. 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 the completion time, to: Chief of Information Resources
Management, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 60611-2092.

For RRB Use: Access ____________________________

Reviewed by: ___________________________________

Form BA-12 (05-09)