Notice of Lien Transmittal Letter

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
844 N. RUSH STREET
CHICAGO, ILLINOIS 60611-2092

N O T I C E

O F

L I E N

SS NO.

OFFICE OF PROGRAMS

NAME, AND ADDRESS

OPERATIONS

OCCUPATION
DATE INJURED

DATE LAST WORKED

The i n d i v i d u a l named above has a p l i e d f o r sickness b e n e f i t s under t h e ail road
Unemployment Insurance Act (RUIAY.
his 1e t t e r i s n o t i c e o f t h e ~ a1 road
i
R e t i rement
Board's (RRB) r i h t t o reimbursement o f such sickness b e n e f i t s from any sum payable on
account o f l i a b i q i t y based on t h e employee's i n j u r y o r i l l n e s s .
Please note t h e p r o v i s i o n s
Section 12(0) o f t h e R U I A i s quoted on t h e enclosed Form SI-5.
o f thaf s e c t i o n concerning t h e l i e n which t h e RRB has when n o t i c e such as t h i s l e t t e r i s
given i n a personal i n j u r y case. I n view o f t h i s l i e n you should see t h a t - t h e RRB i s
u have
p r o p e r l y reimbursed i f any settlement i s made w i t h t h e i n d i v i d u a l . o t h e r ~ i s e ~ y omay
t o reimburse t h e RRB. To p r o t e c t your i n t e r e s t , please f o l l o w these i n s t r u c t i o n s :
1. I f you have l i a b i l i t y insurance, t u r n t h i s l e t t e r over t o your insurance company and

l e t t h e RRB know t h e name and address o f t h e insurance company. F u r t h e r , i f you have
any agreement whereby a t h i r d p a r t y may have assumed l i a b i l i t y , make sure t h a t t h e
t h i r d p a r t y knows about t h i s n o t i c e .

2. Ifi t appears t h a t through l e g a l a c t i o n o r o u t - o f - c o u r t settlement, a sum o r damages
may become payable f o r personal i n j u r y t o t h e employee, please ask t h e RRB by l e t t e r ,
f a c s i m i l e Form ID-3s o r t e l e hone, how much has been a i d i n sickness b e n e f i t s .
Address t h e i n q u i r y t o t h e cyaims adjustment and settyement s e c t i o n a t t h e address
shown above o r telephone (312) 751-4820.
Tele hone i n q u i r i e s received by 2 P.M.
(Central Time) a r e normally answered t h e next u s i ness day.

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3. Ifa sum does become ayable f o r personal i n j u r y , make sure t h a t any amount due i n
Regulations
reimbursement f o r sicRness b e n e f i t s i s w i t h h e l d and p a i d t o t h e RRB
r e q u i r e t h a t you n o t i f y t h e RRB w i t h i n 5 days o f a settlement o r j u i ment and t h a t you
t h e settlement o r
pay t h e RRB t h e amount w i t h h e l d t o s a t i s f y t h e l i e n w i t h i n 30 days
judgement. Report t h e amount o f t h e personal i n j u r y settlement by completeing from SI-5
and sending i t t o t h e RRB w i t h your remittance. Amounts t h a t a r e n o t p a i d w i t h i n 30
days a r e s u b j e c t t o i n t e r e s t charges from t h e date o f settlement o r judgement.

07

If
t h e emDloyee has received, o r i s t o receive, workers'

compensation, please f u r n i s h t h e
YOU a r e n o t t o w i t h h o l d and
i n f o r m a t i o n about such compensation requested on Form SI-5.
pay t o t h e RRB any o f t h e worker's compensation payments b u t t h e RRB needs t o know about
them.
We estimate t h a t Form SI-5-takes
an avera e o f 5 minutes t o complete, i n c l u d i n g t h e t i m e
for reviewing t h e i n s t r u c t i o n s , g e t t i n g t e needed data, and reviewing t h e completed
form.
Federal a encies may n o t conduct o r sponsor, and respondents a r e n o t r e q u i r e d t o
respond t o , a co l e c t i o n o f i n f o r m a t i o n unless i t d i s p l a y s a v a l i d OMB number. Ifyou
wish, send comments regardin t h e accuracy o f our estimate o r any o t h e r aspects of t h y s
form, i n c l u d i n g suggestions ?or reducing t h e completion t i m e t o t h e c h i e f o f Infortnatlan
Mana ement, R a i l r o a d ~ e t i r e m e n tBoard, 844 North Rush s t r e e t , chicago, I L 60611-2092 a d
t o t e Office o f Management and ~ u d g e t , Paperwork ~ e d u c t i o np r o j e c t (3220-0036)
Washington Dc 20503. Please do n o t r e t u r n t h i s form t o e i t h e r o f these addresses.

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Board
S I - l B PROC. DATE
REQ. CODE
06-25-08

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