Form SI-1C (03-09) SI-1C (03-09) Supplemental Information on Accident and Insurance

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U.S. RAILROAD RETIREMENT BOARD

Office of Programs - operations

P. O. Box 10695

Chicago, Illinois 60610-0695

SI-IC (03-09)

11-10-11

111111111111 •• 1•• 1111111.11.1111111111111111.111111.111'111111
In Reply Refer To
SS NO.
REQ ­

REQUEST FOR INFORMATION ON ACCIDENT AND INSURANCE
Information requested on the back of this letter is needed in connection
with your application for sickness benefits for your injUry/illness of
10-24-11. The Railroad Retirement Board's (RRB) authority for requesting
this information is section 5(b) and 12(0) of the Railroad Unemployment
Insurance Act (RUIA). Because you are required to provide this
information under section 9(a) of the RUIA, failure to complete and return
this form could result in a fine or imprisonment or both.
Paperwork Reduction Act Notice: We estimate that this form takes an
average of 5 minutes to complete, including the time 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 completion time, to the Chief of Information Resources Management
Railroad Retirement Board, 844 N. Rush Street, Chicago II 60611-2092.

Robert J. Duda
Director of Operations

Form Approved
OMB No. 3220-0036

SS NO

SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE

1.A. Do you consider that any person or company was responsible for your
injury or sickness? YES
NO
B. If 'YES' give name and address of such person or company.

NAME:

ADDRESS:

2.

Have you filed, or do you expect to file, a claim against such person
or company? YES
NO

3.

Were you injured while on duty?

4.

Did your sickness result from your work?

YES

NO
YES

NO

5.

Where did your injury take place?

6.

What was the date of'your injury or accl.dent?

MONTH

DAY

YEAR

7.A. Were you injured in an automobile accident? YES
NO
B. If 'YES' give the following information about the automobiles

involved:

DRIVER OR DRIVERS:

Name:
Name:

Address:
Address:

OWNER OR OWNERS:

Name:
Address:

Name:

Address:

INSURANCE COMPANY OR COMPANIES REPRESENTING DRIVER OR DRIVERS OF

CAR(S) WHICH CAUSED YOUR INJURY (IF KNOWN). INFORMATION ABOUT YOUR

OWN INSURER IS NOT NEEDED.

Name:
Name:

Address:
Address:

8.

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 the payment of benefits by the RRB.

SIGNATURE
DATE

SI-1C (03-09)

Return this form promptly to the
address shown on the other side.
Failure to return this form within
30 days could delay payment of
benefits to you.