Information Collection

Supplemental Information on Accident and Insurance

IC 33850 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⚠️ Notice: This information collection may be referencing outdated material.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-1C (04-17) Supplemental Information on Accident and Insurance	Form and Instruction
SI-1C (04-17) Supplemental Information on Accident and Insurance Form SI-1c (04-17).pdf	Form and Instruction
ID-30K (05-17) Notice to Request Supplemental Information on Injury or Form ID-30K (05-17).pdf	Form
Form ID-30D (04-06).pdf ID-30D, Request for Information on Injury or Illness	IC Document

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 (04-17)	Supplemental Information on Accident and Insurance	Form SI-1c (04-17).pdf		No		Paper Only
Form	ID-30K (05-17)	Notice to Request Supplemental Information on Injury or Illness	Form ID-30K (05-17).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: 78 FR 58874

Number of Respondents: 530

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	Previously Approved
Annual Number of Responses for this IC	530	530
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ID-30D, Request for Information on Injury or Illness	Form ID-30D (04-06).pdf	09/12/2017

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