Supplemental Information on Accident and Insurance

Documents and Forms

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
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
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
Form ID-30D (04-06).pdf ID-30D, Request for Information on Injury or Illness 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 340 20 CFR 341

Information Collection 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: 1,800	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	1,800	1,270	530
Annual IC Time Burden (Hours)	150	105	45
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.