Form SI-5 (12-93) SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefit

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0036

REPORT OF PAYMENTS TO EMPLOYEE CLAIMING SICKNESS BENEFITS UNDER
THE RAILROAD UPJEMPLQYMENT INSURANCE ACT

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SS NO.
DATF OF INJURY
SECTION 12(0) OF THE RAILROAD UNEMPLOYMENT INSURANCE ACT:
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05-19-08

"Benefits payable t o an employee with respect t o days o f sickness shall be payable regardless o f the liability o f any person
t o pay damages for such infirmity. The Board shall be entitled t o reimbursement from any sum or damages paid or payable
t o such employee or other person through suit. compromise. settlement. judgment. or otherwise on account o f any liability
(other than a liability under a health. sickness, accident or similar insurance policy) based upon such infirmity. t o the extent
that it will have paid or will pay benefits for days o f sickness resulting from such infirmity. Upon notice to the person
against whom such right or claim exists or is asserted, the Board shall have a lien upon such right or claim, any judgment
obtained thereunder. and any sum or damages paid under such right or claim, t o the extent o f the amount t o which the
Board is entitled by way of reimbursement."
NOTICE: The Railroad Retirement Board's (RRB) authority for requesting information about any sum or damages. pay for time
lost. or workers' compensation paid or payable to a railroad employee because o f the employee's infirmity is section 5(b)
and section 9(a) of the Railroad Unemployment Insurance Act

1. D A M A E S (No Dav for time lost) Paid bv Em~lover.or Other Partv
If any sum or damages are paid or payable t o the employee or other person on account o f any liability based on infirmity o f
the above-named employee. and such sum or damages does not include pay for time lost. complete the following:
Net amount of settlement* (not including amount of any expenses shown on the next line): S
Amount o f employee's medical, hospital and legal
expenses in connection with this injury. if known: S

Date o f Settlement:

If any sum or damages are paid or payable t o the employee or other person on account of any liability based on infirmity o f
the above-named employee, and such sum or damages include pay for time lost, complete the following:
Net amount of settlement*
(Not including amount of any expenses shown on the next line): $
Amount of employee's medical, hospital and legal
expenses in connection with this injury, if known: S
Amount o f pay for time lost: S

To

Period to which applicable: From

Date o f settlement:

3.

PAY FOR TIME LOST. Paid bv Emplover

If only pay for time lost has been paid or is payable, complete the following:
Amount o f pay for time lost: S

Date o f payment (if paid):

Period t o which applicable: From

To

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Has workers' compensation been paid, is it being paid, or will it be paid for disability?
No
Yes
If "Yes," is it for permanent total or temporary total?
Yes U N o
. If for permanent total or temporary total.
complete the following:
Amount paid or payable S
Per (week, month, etc.)

q

Payment beginning date

Date first payment made

Payment ending date (if known)
*If amount exceeds

$50,000, enter "In excess
o f $50,000."

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FORM NO. 51-5 (12-93)

Name o f Employer or Other Person

Title