ID-30K-1 (Proposed Notice of Request Supplemental Information on Injury or

PROPOSED

Claimant
Name: SS No.:

Notice to Request Supplemental Information on Injury or Illness
1. Did you make settlement with the above named person:
Yes – Complete Items 2-6 and sign below.
No
Is a personal injury claim still being pursued?
Yes – Complete Items 2 and 3 and sign below.
No – Please explain

2. Enter name, address, telephone, and facsimile (Fax) number of Insurance Company or payer.

Telephone
Number:
3.

(

Fax
Number:

)

Policy No.:

(

)

Claim No.:

4. Date on which the payment was made for settlement:
5. Amount of the payment/settlement:

$

6. Amount withheld from the settlement to repay the
RRB’s lien. If no amount was withheld, please explain:

$

I certify that the information I am giving is true, complete and correct. I understand that criminal and civil
penalties may be imposed against me for false or fraudulent statements or for withholding information to
cause the payment of benefits by the RRB.
Signature:

Date:

Title:

Telephone:

(

)

Privacy Act Notices: The RRB is authorized to collect the information requested on this form under Section 5(b) of the
Railroad Unemployment Insurance Act (RUIA). The information is needed with respect to sickness benefits paid under
the Act. Because you are required to provide this information under Section 9(a) of the RUIA, failure to complete and
return this form could result in a fine or imprisonment or both.

OMB Approval Not Required (<10 Responses Annually)

ID-30K-1 (xx-xx) Destroy Prior Editions