Railroad Unemployment Insurance Act Applications

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0039 can be found here:

Documents and Forms

Document Name Document Type
Form ID-11A (07-07) Railroad Unemployment Insurance Act Applications Form and Instruction
ID-11A (07-07) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (07-07).pdf Form and Instruction
SI-3 (Internet)(10 Claim for Sickness Benefits SI-3 (Internet) (10-10).pdf Form and Instruction
SI-1A (03-12) Application for Sickness Benefits Form SI-1A (03-12).pdf www.rrb.gov/pdf/PandS/ub11.pdf Form
SI-3 (02-09) Claim for Sickness Benefits SI-3 (02-09).pdf Form
UB-11 (03-12).pdf UB-11, Sickness Benefits for Railroad Employees IC Document
Form ID-7H (09-99).pdf ID-7H Non-Entitlement to Sickness Benefits and Information on Unemployment Insurance Benefits IC Document
Form ID-11B (07-07).pdf ID-11B, Notice of Insufficient Medical and Late Filing IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Railroad Unemployment Insurance Act Applications	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 335

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ID-11A (07-07)	Requesting Reason for Late Filing of Sickness Benefit	Form ID-11A (07-07).pdf		No		Paper Only
Form and Instruction	SI-3 (Internet)(10-10)	Claim for Sickness Benefits	SI-3 (Internet) (10-10).pdf		Yes	Yes	Fillable Fileable Signable
Form	SI-1A (03-12)	Application for Sickness Benefits	Form SI-1A (03-12).pdf	http://www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only
Form	SI-3 (02-09)	Claim for Sickness Benefits	SI-3 (02-09).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records
Title: RRB-21-Railroad Unemployment and Sickness Insurance Benefit System	FR Citation: 75 FR 43725

Number of Respondents: 16,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	176,451	18,601	157,850
Annual IC Time Burden (Hours)	16,030	1,489	14,541
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees	UB-11 (03-12).pdf	03/27/2014
ID-7H Non-Entitlement to Sickness Benefits and Information on Unemployment Insurance Benefits	Form ID-7H (09-99).pdf	03/30/2014
ID-11B, Notice of Insufficient Medical and Late Filing	Form ID-11B (07-07).pdf	03/30/2014

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