ID-30D-1, Request for Information on Injury or Illness

In reply refer to
SS No.:
Date of Injury:

In order to update our records, please complete the enclosed Form ID-30K-1, concerning the
individual's personal-injury claim. Return your reply using the enclosed envelope.
Your cooperation in providing a prompt response is greatly appreciated.
Your Policy Number:
Your Claim Number:
Your Insured:
The Railroad Retirement Board's authority for requesting this information is section 5(b) and 12(0) of
the Railroad Unemployment Insurance Act (RLIIA). Because you are required to provide this
information under section 9(a) of the RUIA, failure to complete and return the form could result in a
fine or imprisonment or both.
Sincerely,

Enclosures