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Supplemental Information on Accident and Insurance
Supplemental Information on Accident and Insurance
OMB: 3220-0036
IC ID: 187866
OMB.report
RRB
OMB 3220-0036
ICR 201203-3220-001
IC 187866
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0036 can be found here:
2024-06-27 - Revision of a currently approved collection
2020-11-24 - Revision of a currently approved collection
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
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
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
16,782
0
0
-8,718
0
25,500
Annual IC Time Burden (Hours)
842
0
0
-601
0
1,443
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.