Form BA-12 (xx-xx) Application for Employer Reporting Internet Access

Proposed
United States of America
Railroad Retirement

Form Approved
OMB No. 3220-0008

Application for Employer Reporting Internet Access
General Instructions – This form may be used by employers covered under the Railroad Retirement and Railroad
Unemployment Insurance Acts to add, modify, or terminate employee access to the Railroad Retirement Board’s (RRB)
Employer Reporting System (ERSNet). You may request system access for one or more employees, and you may
authorize different levels of access for each employee. You may also request that an individual employee file online
reports on behalf of one or more subsidiary or affiliate employers. In each case, your employees must certify that they will
adhere to the RRB’s security guidelines, which include the use of an authoritative electronic signature. The Security
Guidelines are under Part VIII, Chapter 8 of the Reporting Instructions on the RRB’s website.
•

To request new or modified system access, complete the entire form.

•

To terminate an employee’s access, complete only Sections A, B(1-4), D1, and E.

Making representations on this form to gain unauthorized access to the RRB Employer Reporting System or
using an authorized access for fraudulent purposes is a violation of federal law punishable by fine,
imprisonment, or both.
We estimate this form takes an average of 15 to 25 minutes per response to complete, including the time needed for
reviewing the instructions, getting the needed data, and reviewing the completed form. Federal agencies may not conduct
or sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB
number. If you wish, send comments regarding the accuracy of our estimate or any other aspect of this form, including
suggestions for reducing the completion time, to: Associate Chief Information Officer for Policy and Compliance, Railroad
Retirement Board, 844 N. Rush Street, Chicago, IL 60611-1275.
Section A
Employer Information
In this section, enter the BA number, name, and address of the employer whose reports will be accessed online.
Special Instructions to Request Access on Behalf of Multiple Employers – If you are requesting the same level of
access for the employee listed in Section B on behalf of multiple employers, list all affected BA numbers in Item 1. If you
are requesting different levels of access for this employee for different employers, file a separate application for each
level of access.
1.

BA Number(s):

2.

Name and Address of Employer – If you are requesting access on behalf of multiple employers, provide only the
name and address of the employer serving as primary contact for this account.

Section B
1.

Name:

2.

Title

Employee Information
3.

Telephone Number
(

4.

E-Mail Address

)

5. I have read the document “Security Guidelines” and agree to comply with these guidelines. I have provided a state
and/or federal government-issued photo ID to the authorizer named in section E. I understand that my logon, if used
to file forms, has the same status as a signature on a paper document. I also understand that providing false or
fraudulent information through the RRB Employer Reporting System is a violation of federal law punishable by fine,
imprisonment, or both.
Signature: _____________________________________________________

Date: _______________________
Form BA-12 (XX-XX)

Section C
Group or Section E-Mail Address to Receive Notices
Complete this section only if you prefer to designate a group or section e-mail address as the default address for RRB
work notices, rather than the e-mail address listed in Section B above.
1.

Default E-Mail Address:

2.

If you have more than one group or section e-mail address, number each address and specify here which forms or
group of forms are associated with each address.

Requested Action and Level of Access
Add New User
Action (check appropriate box)

Section D
1.
2.

Modify Access

Terminate Access

Explanation of the Levels of Access Used in Section F on the next page.
R
Reader
User can only view the forms. Restricts access to “read only.”
User has access to complete or “update” a form that changes the RRB's record of service and
U
Updater
compensation. User cannot submit the form to the RRB without authorization.
User has access to approve, update, certify and submit forms to the RRB. Level “A” access is
A
Approver
appropriate for personnel who work independently and supervisory approval is not needed.
X
Terminate User is prohibited from access to ERSNet or a particular form.
For additional information on levels of access, see Part VIII, Chapter 2 of the Reporting Instructions.

Section E
Certification of Authority to Approve Access
The form must be signed by an official with signature authority to sign RRB forms for the employer(s) listed in Section A.
Signatures of two individuals are not required if the employee listed in Section B has authority to sign RRB forms. The
head of the company and those persons designated on Form G-117A, Designation of Contact Official, have signature
authority. A contact official may assign signature authority to a designee, but the RRB will verify with the contact official
any signatures other than those of a contact official.
1. Name (Print)
2. Title
3. Telephone Number

(

4.

)

I have signature authority to approve this request and authorize the RRB to grant access as indicated above. I
understand that I am acting as a trusted referee on behalf of the RRB and I have identity proofed the applicant by
resolving, validating, and verifying a state and/or federal government-issued photo ID from the applicant. I also
understand that I am responsible for notifying the RRB if, in the future, this individual’s access should be terminated.
Signature: _____________________________________________________

Date: _____________________

Questions? Please contact the System Administrator at (312) 751-4961 or the Quality Reporting Service Center at (312) 751-4992.

Mail this completed application to:

Quality Reporting Service Center
Railroad Retirement Board
844 N. Rush Street
Chicago, IL 60611-1275

For RRB Use: Access _______________________________

Reviewed by: __________________________________________

Continued on Next Page
Page 2

Form BA-12 (XX-XX)

Section F

Forms and Levels of Access

Check one box for each form. Note: Employee’s level of access will apply for all employers listed in Section A.1.
Form BA-3, Annual Report of Creditable Compensation

R

U

A

X

Form BA-4, Report of Creditable Compensation Adjustments

R

U

A

X

A

X

Form BA-6a, Form BA-6 Address Report
Form BA-9, Report of Separation Allowance or Severance Pay

R

U

A

X

Form BA-11, Report of Gross Earnings

R

U

A

X

Form G-73a.1, Notice of Death of Railroad Retirement Annuitant

R

Form G-88A.1, Request for Verification of Last Date Carried on Payroll

R

U

A

X

Form G-88A.2, Notice of Retirement and Request for Service Needed for
Eligibility

R

U

A

X

Form G-88P, Employer’s Supplemental Pension Report

R

U

A

X

Form G-117A, Designation of Contact Officials

A

X

Form GL-129a, Record of Employer Determination on Employee Protest of
Service and Compensation

A

X

Form ID-3s, Request for Lien Information; Report of Settlement

A

X

Form ID-3u, Request for Section 2(f) Information

A

X

X

Form ID-4E, Notice of RUIA Claim Determinations

R

A

X

Form ID-4K, Prepayment Notice of Employees' Applications and Claims for
Benefits under RUIA

R

A

X

Form ID-6, Report of Tier I Tax Transactions

R

X

Form ID-6Y, Annual Summary of Tier I Tax Transactions

R

X

Form ID-30b, Notice of Lien

R

X

R

X

R

X

Form RL-5a, Notice to Employer of Annuity Award

R

X

Form SI-5F (SUP), Status Report – Personal Injury Claims

R

Form ID-40Q, Quarterly Notice to Employers – Railroad Unemployment Insurance
Act
Form ID-40R/S, Annual Notice to Employers – Railroad Unemployment Insurance
Act and Annual Proclamation

Page 3

A

X

Form BA-12 (XX-XX)