Supplemental Information on Accident and Insurance

Supplemental Information on Accident and Insurance

OMB: 3220-0036

IC ID: 187866

Information Collection (IC) Details

View Information Collection (IC)

Supplemental Information on Accident and Insurance
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 340 20 CFR 341

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

Litigation and Judicial Activities Resolution Facilitation

RRB-21, Railroad Unemployment and Sickness Benefit System   73 FR 73514

1,325 0
   
Private Sector Businesses or other for-profits
 
   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

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.

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