Information Collection

Supplemental Information on Accident and Insurance

IC 187866 under ICR 201203-3220-001 · OMB 3220-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SI-5 (12-93) Supplemental Information on Accident and Insurance	Form and Instruction
SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefit Form SI-5 (12-93).pdf	Form and Instruction
ID-3S (03-09) Request for Lien Information; Report of Settlement Form ID-3s (03-09).pdf	Form and Instruction
ID-3S-1 (03-09) Lien Information Under Section 12(o) of the RUIA Form ID-3S-1 (03-09).pdf	Form and Instruction
ID-3U (03-09) Request for Section 2(f) Information Form ID-3u (03-09).pdf	Form and Instruction
ID-30K-1 (03-02) Request for Supplemental Information on Injury or Illnes Form ID-30K-1 (03-02).pdf	Form and Instruction
Form ID-30B-1 (02-99).pdf Notice of Lien Transmittal Letter	IC Document
Form ID-30B-2 (02-99).pdf Notice of Lien Transmittal Letter	IC Document
Form ID-30B (02-99).pdf Notice of Lien Transmittal Letter	IC Document
Program Letter(2-06) E-Mail requests.pdf Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements	IC Document
Form ID30D1 (04-06).pdf ID-30D-1, Request for Information on Injury or Illness	IC Document

IC Title:

Supplemental Information on Accident and Insurance

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 340 20 CFR 341

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SI-5 (12-93)	Report of Payments to Employee Claiming Sickness Benefits Under the RUIA	Form SI-5 (12-93).pdf	No		Paper Only
Form and Instruction	ID-3S (03-09)	Request for Lien Information; Report of Settlement	Form ID-3s (03-09).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-3S-1 (03-09)	Lien Information Under Section 12(o) of the RUIA	Form ID-3S-1 (03-09).pdf	No		Paper Only
Form and Instruction	ID-3U (03-09)	Request for Section 2(f) Information	Form ID-3u (03-09).pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-30K-1 (03-02)	Request for Supplemental Information on Injury or Illness - 3rd party	Form ID-30K-1 (03-02).pdf	No		Paper Only

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records

Title: RRB-21, Railroad Unemployment and Sickness Benefit System

FR Citation: 73 FR 73514

Number of Respondents: 1,325

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	16,782	-8,718	25,500
Annual IC Time Burden (Hours)	842	-601	1,443
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Notice of Lien Transmittal Letter	Form ID-30B-1 (02-99).pdf	01/26/2009
Notice of Lien Transmittal Letter	Form ID-30B-2 (02-99).pdf	01/26/2009
Notice of Lien Transmittal Letter	Form ID-30B (02-99).pdf	01/27/2009
Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements	Program Letter(2-06) E-Mail requests.pdf	01/27/2009
ID-30D-1, Request for Information on Injury or Illness	Form ID30D1 (04-06).pdf	01/27/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.