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Federal forms, ICRs, and supporting documents

Information Collection

Supplemental Information on Accident and Insurance

IC 187866 under ICR 202406-3220-005 · OMB 3220-0036.

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Information Collection (IC) Details

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Supplemental Information on Accident and Insurance
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 341 20 CFR 340

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefits Under the RUIA Form SI-5 (12-93).pdf No   Paper Only
Form and Instruction ID-3S (03-09) Request for Lien Information; Report of Settlement Form ID-3S (03-09).pdf Yes Yes Fillable Fileable Signable
Form and Instruction ID-3S-1 (08-17) Lien Information Under Section 12(o) of the RUIA Form ID-3S1 (08-17).pdf No   Paper Only
Form and Instruction ID-3U (03-09) Request for Section 2(f) Information Form ID-3u (03-09).pdf Yes Yes Fillable Fileable Signable
Form and Instruction ID-3S (Internet) (09-14) Request for Lien Information; Report of Settlement Form ID-3S (Internet) (09-14) Screens.pdf https://secure.rrb.gov/ERSNet/login.aspx Yes Yes Fillable Fileable
Form and Instruction ID-3U (Internet) (09-14) Request for Section 2(f) Information Form ID-3U (Internet) (09-14) Screens.pdf https://secure.rrb.gov/ERSNet/login.aspx Yes Yes Fillable Fileable
Form and Instruction ID-3S (xx-xx) Request for Lien Information: Report of Settlement Form ID-3S (Paper) - Proposed (xx-xx).pdf Yes Yes Fillable Fileable Signable
Form and Instruction ID-3U Request for Section 2(f) Information Form ID-3U (Paper) - Proposed (xx-xx).pdf Yes Yes Fillable Fileable Signable

Litigation and Judicial Activities Resolution Facilitation

RRB-21, Railroad Unemployment and Sickness Benefit System   79 FR 58874

9,156 0
   
Private Sector Businesses or other for-profits
 
   39 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 9,156 0 2,056 0 0 7,100
Annual IC Time Burden (Hours) 462 0 104 0 0 358
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Notice of Lien Transmittal Letter Form ID-30B-1 (08-17).pdf 09/22/2017
Notice of Lien Transmittal Letter Form ID-30B-2 (08-17).pdf 09/22/2017
Notice of Lien Transmittal Letter Form ID-30B (08-12).pdf 07/16/2014
Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements Program Letter (06-05) for E-Mail requests.pdf 09/12/2017
ID-30D-1, Request for Information on Injury or Illness Form ID-30D-1 (04-06).pdf 07/16/2014
Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f) Program Letter (07-02) for ERs under 2(f) & 12(o).pdf 09/12/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.