Information Collection

Supplemental Information on Accident and Insurance

IC 187866 under ICR 201709-3220-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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-5 (12-93) Report of Payments to Employee Claiming Sickness Benefits Under the RUIA Supplemental Information on Accident and Insurance	Form and Instruction
Form ID-3S (03-09) Request for Lien Information; Report of Settlement Supplemental Information on Accident and Insurance	Form and Instruction
Form ID-3S-1 (08-17) Lien Information Under Section 12(o) of the RUIA Supplemental Information on Accident and Insurance	Form and Instruction
Form ID-3U (03-09) Request for Section 2(f) Information Supplemental Information on Accident and Insurance	Form and Instruction
Form ID-30K-1 (05-17) Request for Supplemental Information on Injury or Illness - 3rd party Supplemental Information on Accident and Insurance	Form and Instruction
Form ID-3S (Internet) ( Request for Lien Information; Report of Settlement Supplemental Information on Accident and Insurance	Form and Instruction
Form ID-3U (Internet) ( Request for Section 2(f) Information Supplemental Information on Accident and Insurance	Form and Instruction
SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefit Form SI-5 (12-93).pdf	Form and Instruction
ID-3S (03-09) Request for Lien Information; Report of Settlement Form ID-3S (03-09).pdf	Form and Instruction
ID-3S-1 (08-17) Lien Information Under Section 12(o) of the RUIA Form ID-3S1 (08-17).pdf	Form and Instruction
ID-3U (03-09) Request for Section 2(f) Information Form ID-3u (03-09).pdf	Form and Instruction
ID-30K-1 (05-17) Request for Supplemental Information on Injury or Illnes Form ID-30K-1 (05-17).pdf	Form and Instruction
ID-3S (Internet) ( Request for Lien Information; Report of Settlement Form ID-3S (Internet) (09-14) Screens.pdf secure.rrb.gov/ERSNet/login.aspx	Form and Instruction
ID-3U (Internet) ( Request for Section 2(f) Information Form ID-3U (Internet) (09-14) Screens.pdf secure.rrb.gov/ERSNet/login.aspx	Form and Instruction
Form ID-30B-1 (08-17).pdf Notice of Lien Transmittal Letter	IC Document
Form ID-30B-2 (08-17).pdf Notice of Lien Transmittal Letter	IC Document
Form ID-30B (08-12).pdf Notice of Lien Transmittal Letter	IC Document
Program Letter (06-05) for E-Mail requests.pdf Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements	IC Document
Form ID-30D-1 (04-06).pdf ID-30D-1, Request for Information on Injury or Illness	IC Document
Program Letter (07-02) for ERs under 2(f) & 12(o).pdf Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SI-5 (12-93)		No		Paper Only
Form and Instruction	ID-3S (03-09)		Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-3S-1 (08-17)		No		Paper Only
Form and Instruction	ID-3U (03-09)		Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-30K-1 (05-17)		No		Paper Only
Form and Instruction	ID-3S (Internet) (09-14)	https://secure.rrb.gov/ERSNet/login.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	ID-3U (Internet) (09-14)	https://secure.rrb.gov/ERSNet/login.aspx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records

Title: RRB-21, Railroad Unemployment and Sickness Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 1,325

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 77 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	9,672	-600	10,272
Annual IC Time Burden (Hours)	486	-30	516
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Notice of Lien Transmittal Letter		09/22/2017
Notice of Lien Transmittal Letter		09/22/2017
Notice of Lien Transmittal Letter		07/16/2014
Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements		09/12/2017
ID-30D-1, Request for Information on Injury or Illness		07/16/2014
Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f)		09/12/2017

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].