Information Collection

Supplemental Information on Accident and Insurance

IC 33850 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⚠️ Notice: This information collection may be referencing outdated material.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-1C (03-09) Supplemental Information on Accident and Insurance	Form and Instruction
SI-1C (03-09) Supplemental Information on Accident and Insurance Form SI-1c (03-09).pdf	Form and Instruction
ID-30K (03-02) Notice to Request Supplemental Information on Injury or Form ID-30K (03-02).pdf	Form

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 341 20 CFR 340

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SI-1C (03-09)	Supplemental Information on Accident and Insurance	Form SI-1c (03-09).pdf		No		Paper Only
Form	ID-30K (03-02)	Notice to Request Supplemental Information on Injury or Illness	Form ID-30K (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 Insurance Benefit System

FR Citation: 75 FR 43725

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	600	-2,400	3,000
Annual IC Time Burden (Hours)	50	-200	250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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