SI-1A (03-12) Application for Sickness Benefits

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039

Application for Sickness Benefits
Section A
1.

Identifying Information

Employee’s Name (First, Middle Initial, and Last)

2. Social Security Number

Employee’s Street Address, City, State and ZIP Code
(Including Apartment Number)

4. Date of Birth
Month
Day

–

3.

–
5. Sex

Year

 Male
 Female

6. Telephone Number (Include Area Code)

(
Section B

)

Infirmity and Employment Information

7.

Date You Became Sick or Injured

8.

Date You Last Worked for a Railroad

9.

Last Railroad Employer (Name of Company)

10. Location of Last Railroad Employment (City/State)
11. Last Railroad Occupation
12. Department
13. If you worked for a nonrailroad employer after the date shown in Item 8, complete Items A, B, and C, below. Otherwise, go to Item 14.
A. Last Nonrailroad Employer (Name of Company)
B. Last Occupation After Railroad Work
C. Date Last Worked After Railroad Work

Section C

Accident and Insurance Information

14. Are you applying for sickness benefits because you were injured at work or have a work-related illness?  Yes
15. Have you filed or do you expect to file a lawsuit or claim against any person or company for personal injury?

 No

 No - Go to Item 16
 Yes - Complete Items A-D, below
A. Furnish the name and complete address of the person or company.
Name
Address
City, State, ZIP Code
B. Give the place where the injury occurred.
C. Were you injured in an automobile accident?

 Yes

 No - Go to Item 16

D. If you were injured in an automobile accident, provide information about all the vehicles, other than your own, that were
involved in the accident that caused your injury. Information about your vehicle and insurance company is not needed. If you
need more space attach a separate sheet of paper.

Owner of Car (other vehicle)

Driver (other vehicle)

Name

Name

Address

Address

City, State, ZIP Code

City, State, ZIP Code

Insurance Company (other vehicle)

Policy Information (other vehicle)

Name

Policy Number

Address

Claim Number

City, State, ZIP Code

Continued on Next Page

SI-1a (03-12)

Section D

Claim for Sickness Benefits Information

16. Enter the earliest date you wish to claim sickness benefits. _________________________________________________________
17. Are you claiming all the days of sickness beginning with the date you entered in Item 16? (Note: You may claim rest days if you
were unable to work and did not receive pay from your employer.)
 Yes - Go to Item 19  No - Go to Item 18
18. Enter any dates that you do not wish to claim. ___________________________________________________________________
19. Enter the date you returned to work (if applicable). _______________________________________________________________
20. You must complete all boxes to indicate if you have received or will receive any of the following payments for your days of sickness.
If you check “YES” for any item, be sure to provide the requested information.
A. WAGES (Include Railroad and Nonrailroad Wages)
YES NO If “YES,” show the dates for which you were paid in Month/Day/Year format below.

 Regular Wages. . . . . . . . . . . .. . . . . ________________________________________________________________

 Vacation Pay . . . . . . . . . . . . . . . . . . ________________________________________________________________

 Holiday Pay . . . . . . . . . . . . . . . . . . ________________________________________________________________

 Military Reservist Pay . . . . . . . . . . ________________________________________________________________

 Wage Continuation Pay . . . . . . . . . ________________________________________________________________

 Earnings from Self-Employment . . ________________________________________________________________

 Sick Pay from Your Employer . . . . ________________________________________________________________
(but not payments supplementing Railroad Retirement Board (RRB) benefits. See Booklet UB-11)
B. GOVERNMENTAL PAYMENTS (Not RRB Sickness Benefits)
YES NO If “YES,” enclose copy of award letter and complete Items 1 - 3 below.

 Sickness or Unemployment Benefits Under Any Other Law
1. Beginning Date of Payment

 Social Security Benefits
2. Gross Amount of Payment $ __________________

 Railroad Retirement or Disability Annuity
3. How often do you receive the payment?

 Military Retirement Pay
 Weekly  Monthly  Yearly

 Worker’s Compensation
 Other: ________________________________

 Retirement Payments Under Another Law
C. OTHER PAYMENTS
YES NO If “YES,” complete Items 1 and 2.

 Settlement, Judgment or Damages for Personal Injury

 Advances

 Separation Allowance (Buyout, Severance Pay)

1. Date of Payment
2. Paid By: __________________________________

21. If the date you are submitting this form is more than 30 days after the date you entered in Item 16, answer the following:
A. Why did it take more than 30 days to submit this form? If more space is needed, attach a separate sheet of paper.
______________________________________________________________________________________________________
B. How did you obtain this form? _____________________________________________________________________________
C. Who provided this form to you? ____________________________________________________________________________
D. On what date did you obtain the form? ______________________________________________________________________
E. Furnish the name and title of any person from whom you asked for help in completing and filing the forms.
NAME_______________________________________________________ TITLE ___________________________________

Section E

Direct Deposit Information

22. Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To provide

the information we need to correctly deposit your payments, attach a voided personal check and go to Item 23, or call your financial institution for the information you need to complete Items A-E.
A. Routing Transit Number
C. Account Type:
 Checking  Saving

Section F

B. Account No. _______________________________
D. Name of Financial Institution: _________________________________________
E. Telephone No. (Include Area Code) (_______)____________________________

Certification and Signature

23. I waive any ”doctor-patient privilege” I may have with respect to the disclosure of information concerning the period of sickness or injury on

which my claim is based. I certify that I understand and agree to the requirements in Booklet UB-11. I know that disqualification and civil and
criminal penalties may be imposed on me for false or fraudulent statements or claims or for withholding information to get benefits from the
RRB. I affirm that the information given on this form is true, correct and complete. NOTE: If the sick or injured employee is unable to sign
this form, sign your name and complete Section 1 of the attached Form SI-10, Statement of Authority to Act for Employee.

SIGNATURE ______________________________________________________________________ DATE __________________
SI-1a (03-12)

HAVE YOUR DOCTOR COMPLETE THE ATTACHED STATEMENT OF SICKNESS