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⚠️ Notice: This information collection may be referencing outdated material.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 (04-17) Railroad Unemployment Insurance Act Applications Form and Instruction
ID-11A (04-17) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (04-17).pdf Form and Instruction
SI-3 (Internet)(10 Claim for Sickness Benefits Form 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 Form SI-3 (02-09).pdf Form
UB-11 (03-12).pdf UB-11, Sickness Benefits for Railroad Employees 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 (04-17)	Requesting Reason for Late Filing of Sickness Benefit	Form ID-11A (04-17).pdf		No		Paper Only
Form and Instruction	SI-3 (Internet)(10-10)	Claim for Sickness Benefits	Form 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	Form 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: 79 FR 58874

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	209,168	32,717	176,451
Annual IC Time Burden (Hours)	18,732	2,702	16,030
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

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