SI-3 (Internet)(08 Claim for Sickness Benefits

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Unrted Stales of America - Railroad Retirement Boar�

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Claim for Sickness Benefits -- Form S1-3

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About Us Privacy Security
51-3 (08-21)
Form Approved
0MB No, 3210--0039

Introduction Page
Welcome to the Railroad Retirement Board's On-line Claim for Sickness Benefits.
Only residents of the United States can use this on-line claim. If you live outside the United States, mail your paper claim to your nearest RRB field office.
Before completing your claim form, please careful� read the section titled "Claim for Sickness Benefits (Form Sl-3)" in the Booklet UB-11, Sickness Benefits for Railroad
Employees or Booklet UB-11s. Beneficios de Enferrnedad Para Empleados Ferroviarios.
IMPORTANT: The time limit for filing your claim is 30 days from the last day of the claim period or 30 days from the date the form was available on the Internet,
whichever is later.
Waiting Period/Benefit Payments -- If this is your first claim in a period of sickness and you have not previously saUsfied the benefit year waiting period requirement, benefits
will be paid to you for the days you were sick over 7 in the period. Otherwise. benefits are normally payable for the number of days of sickness over 4 in each claim period.
Allow up to 15 calendar days from the date you submit your claim on the lriternet for a paymem to be received. If you do not receive a payment or other notice within 15 days,
contact your local RRB office for information about the status of your claim.
RAILROAD RETIREMENT BOARD
HALE BOGGS FEDERAL BLDG
SUITE 1045
500 POYDRAS STREET
NEW ORLEANS LA 70130
1877) 772-5772
RRB HelpLine - For information abotJt the benefits paid to you or to check on the status of your claim form, use the view RUIA Account Statement Service on our website under
Benefit Online (Mainline) Services.

Direct Deposit - If you are not current~ receiving payments by Direct Deposit and wish to sign up, please contact your local RRB orlice.

I
I Amount
I $192.00
I $64□.oo
I $640.00

Record of Recent Benefit Payments:

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Type
SI
SI
SI

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Claim Beginning
01/25/2010
01/1112010
12/28/2009

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Date Approved
02/2512010
0210512010
0210512010

Click here to read these important notices:
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Nondiscrimination on the Basis of Disability
Fraud and Abuse Hot Line

Claims:
The following claim(s) are available for completion If you do not wish to file on the Internet, please file the paper claims we mailed to you. Do not file both a paper and Internet
claim for the same claim period. To begin your claim for sickness benefits, click on one of the claim periods listedbelow.

Claim(sj that are currently available for completion:

Claim(s) Available for Completion

07i15/2010through 0712812010

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To return to the Benefit Online (Mainline) Services Menu to do additional private, secure business with us, click here

8/412010

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Unrtod States of Aln!n:o. Ru·oad Rl!lrtment Beard

Pro,idiltg SeclAJ'e lnttrnetStr,·ices ro th; R4iltoad CoJ0111uu,it:,·

Claim for Sickness Benefits - Form S1-3

1. This claimis for sickness benefits for Thursday, Jul 15, 2010 through Wednesday, Jul 28, 2010. To claim benefits, enter or select the appropriate code (X,E,P, or 0 1in the
box under each date.
Jul 15

Jul 16

Jul 17

Jul 21

LFJ

Jul22

Jul23

rn

Jul 24

Jul2S

V

P . Vacabon or holiday pay; (Do not report supplemental sickness benefits)
0 . Day not claimed, other reason
Ye,

No

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3. Your claimwill be processed by this RRB Office:

HALE BOGGS FEDERAL BLDG

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500 POYDRAS STREET
NEW ORI.EAJIS LA 70130

(STT)n2-S772

SI-3 (10,10)
Form Approved

0MB llo, 3220~39

Jul27

Jul28

V

X • Claimed day of sickness (Including rest days);
E - Day employed (Include railroad, nonrailroad, or se~_employment);

2A. Have you returned to work?

Jul26

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Remember that you cannot claim benefits
for any day on which you worked or
otherwise earned regular wages,
vacation pay, holiday pay, military
reservist pay, wage continuation pay, sick
pay (excluding supplemental sickness
benefitsl, or other pay. This includes pay
from full-time and pan-time work in either
railroad or nonrailroad employment.

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Claim for Sickness Benefits -- Form S1-3

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1. This claim is for sickness benefits for Thursday, Jul 15, 2010 through Wednesday, Jul 28, 2010. To claim benefits, enter or select the appropriate code (X,E,P, or 0) in the
box under each date.
Jul IS

Jul16

X ..,

X

Jul 19

Jul 20

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V

Jul 21

Jul22

Jul23

X "

X ·..,

Jul 24

Jul2S

X "

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X - Claimed day of sickness (lnduding rest days);
E - Day employed (lndude railroad, nonrailroad, or self_employment);
P - Vacation or holiday pay; (Do not report supplemental sickness benefits)
o -Daynot claimed, other reason
Yes

2A. Have you returned to work?

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No

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3. Your claim will be processed by this RRB Office:

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H.1\1.E BOGGS FEDfRAL BUXl

SUITE 1045
cOO POYDRAS STREET

NEW ORLEANS LA 70130
(8n)7n-5772

Sl-3(1O-10]
Form Approved
OMS Ho. 3120-0039

Next Page

Jul 26

Jul 27

Jul 28

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If you have recovered from your infirmity '
and have returned to work, check
the "Yes" box and enter the date here. If
you anempted to return to work but found
that you were not able to continue
working, check the "NO" box and
indicate, in item 1, the days you worked
and received wages, but do not enter a
return-to-work date in this Item.

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Unleo States of America. Ralroed Retirement Board
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Claim for Sickness Benefits •· Form S1-3

The time limit for filing your claim is 30 days from the last day of the claim period or 30 days from the date the form was mailed to you and made available to you online, whichever is later. The
30 days ended on 9/3/2010.
II you tried to file your claim earlier but were prevented from doing so by circumstances beyond your control, your claim may be considered as filed on time.
An employee's lack of knowledge about the filing requirements Is not considered to be a circumstance beyond his or her control.
Please provide the following Information In the space below for your explanation for late filing:
What actions did you take to obtain and complete your claim for sickness benefiis? Provide the dates you took these actions.
Provide the names and titles of any persons who helped you complete and file your claim.

Characters Remaining:

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IPre-..,ous Page I
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S1-3 (10..10)
' orm Approved
:JMB No. 322().0039

Your claim should be filed within thj
later of 30 days after claim end date
or alter the dare the claim was made
available. Please explain why the
claim is being filed late.
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About Us I Privacy I Security

Uoleo States of Amer~ - Ra•oad Re:J:emeot Board

Pro,iding S,cw, lncmw S,r,.ic,s co cit, Railroad ColftlltunilJ·

Claim for Sickness Benefits -- Form S1-3
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If yourr ame or address is incorrect, make corrections below.

Name (First lnlt, Mid lnit, Last)

This item is prefilled with your name and
address. If necessary, make corrections to
your name and address in the box.

Mailing Address
Address Continued
City
State

ZIP Code
Phone Number:

Sl-3110-10)
form Approved

0MB No, 3220-0039

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Claim for Sickness Benefits -· Form S1-3
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You must click "Yes" or "No" to show if you have received or will receive each of the following payments for your days of sickness.

5A. Wages (Include railroad and nonrailroad wages) - If "Yes," enter dates for which paid in
MM/0D/YYYY format.
1 Regular Wages

YES

NO

• □

D

2Vacation Pay

D

3 Holiday Pay

•□

D

4 Military Reservist Pay

•□

D

S1-3 (10-101
f orm Approved
0 MB No. 3720-0039

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Regular Pay .. Pay for lime worked,
including full.time and part.time work.
Wages are payments that you receive
from your employer, from a
nonrailroad employer or your own
business for services you performed.
Benefits are not payable for any day
for which you receive wages.

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Unl ed States of Amenca • Ro,lro,d Retsemont Bo,rd
Pr0<-i,/J,,g Stt,,r, Inttrnlt ~nicts to tlit Raiu-oa.d Conllflunlly

Claim for Sickness Benefits -- Form S1-3

You must click "Yes• or "No" to show if you have received or will receive each of the following payments for your days of sickness.

5A. Wages (Include railroad and nonrailroad wages) - If "Yes," enter dates for which paid In
MMIDD/YYYY format
5 Wage Continuation Pay

YES

NO

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6 Earnings From Self-Employment

□

7 Sick Pay From Your Employer

□

St-; 110-101
=orm Approved
:>MB llo. 32~ -0039

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Wage Continuation Pay - Salary or
wages paid by your railroad employer
when you have been Injured on-duty. The
purpose of the payments is to continue
your wage or salary, not to supplement
RRB benefits. The payments are subject
to normal payroll deductions. Wages are
payments that you receive from your
1employer, from a nonraifroad employer
or your own business for services you
performed. Benefits are not payable for
any day for which you receive wages.

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Claim for Sickness Benefits -- Form S1-3

You must click "Yes" or "No" to show if you have received or will rec1ive any of the following payments for your days of sickness.

5B. Government.ii Payments (Not RRB Sickness Benefits) - If " Yes," enter the Date, Amount, and how
often for any item.

1 Sickness or Unemployment Benefits Under Any Other Law

YES

NO

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II Beglnn11g D,te of Plrmont I
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2 Social Security Benefits

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3 Railroad Retirtment or Disability Annuity

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0MB llo. 3220-0039

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Sickness or Unemployment Benefits
under any Other Law are benefits paid to
you on account of sickness or
unemployment by a county, city or state
government. or by another Federal
agency. Governmental payments are
annuities or other payments made to you
by II county, city, state, or Federal
Government If you are receiving or will
receive a governmental payment, check
the appropriate box and give the
beginning date, the gross amount, and

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Unllerl Stat!'s of A,menca - Railroad Retirement Board

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Claim for Sickness Benefits -- Form S1-3

You must click "Yes" or "No" to show if you have received or will receive any of the following payments for your days of sickness

5B. Governmental Payments (Not RRB Sickness Benefits) - If "Yes,"enter the Date, Amount, and how
often for any item.
4 Military Retirement Pay
I P.

YES

NO

•□

□

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Military Retirement Pay is an annuity,
pension or retainer pay paid to you by
the Federal Government based on you
military service. Governmental payments
are annuities or other payments made to
you by a county, city, state, or Federal
Government. If you are receiving or will
receive a governmental payment, check
the appropriate box and give the
beginning date, the gross amount, and
the frequency of the payment.

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5 Worker's Compensation

II B~11n,g Date of Pavmeot l
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13-Hew oft«i do yo.u l'eeel'l-"t the payment':"

Grow Amount of Pa)'nll:i'nt

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6 Retirement Payments Under Another Law

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Fo,·m Approved

OMS No. m MB No. 3210.0039

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About Us IPrivacy ISecLtrity

unteil States cf Atr.enca - Railroad Relxement Board

Pro,.•ulhtg Stcurt Inu!'lltt s,,..icts w drt Railtoad Corumnur

Claim for Sickness Benefits
•· Form S1-3
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Claim Review andCertification Statement •• October 06, 2010, 09:29 AM, EST.

Please reviewyour answers below Tomake corrections, click on the tabs above to return to the section of the application you want to correct. Alter making any corrections, click on
the "Certification" tab at thetop of the page to return to this page.Then complete the Certification at the botlom.
Your Name
1. This claim is for sickness benefits for the period July 15, 2010 through July 28, 2010.
Ju~ 15 X. Claimed dayof sickness (Including rest days)
Ju~ 16 X. Claimed day of sickness (lnduding rest days)
Ju~ 17 X. Claimed dayof sickness (Including rest days)
Ju~ 18 X. Claimed day of sickness (lnduding rest days)
Ju~ 19 X. Claimed day of sickness (lnduding rest days)
July 20 X. Claimed dayof sickness (lnduding rest days)
Ju~ 21 X. Claimed dayof sickness Oncluding rest days)
Ju~ 22 X. Claimed day of sickness (lnduding rest days)
Ju~ 23 X. Claimed day of sickness (lnduding rest days)
July24 X. Claimed day of sickness (lnduding rest days)
Ju~ 25 X. Claimed day of sickness (Including rest days)
Ju~ 26 X. Claimed day of sickness (lnduding rest days)
Ju~ 27 X. Claimed dayof sickness (lnduding rest days)
July28 X. Claimed day of sickness (Includingrest days)

2. Have you returned to work? No
3. Y~r claim wm be submitted to the following address:
U.S. RAILROAD RETIREMENTBOARD
HALEBOGGS FEDERALBLDG
SUITE 1045
500 POYDRAS STREET
NEW ORLEANSLA 70130
(877) 772-5772