Supplemental Information on Accident and Insurance

OMB 3220-0036

The Railroad Unemployment Insurance Act provides for the recovery of sickness benefits paid if an employee receives a settlement for the same injury for which benefits were paid. The collection obtains information that is needed to determine the amount of the RRB's reimbursement from the person or company responsible for such payments.

The latest form for Supplemental Information on Accident and Insurance expires 2021-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SI-1C (04-17) Supplemental Information on Accident and Insurance Form and Instruction
Form SI-5 (12-93) Supplemental Information on Accident and Insurance Form and Instruction
3220-0036.docx Supporting Statement A
Supplemental Information on Accident and Insurance Form and Instruction
Supplemental Information on Accident and Insurance Form and Instruction

All Historical Document Collections

202406-3220-005 Approved without change	Revision of a currently approved collection	2024-06-27
202011-3220-001	Revision of a currently approved collection	2020-11-24
201709-3220-001 Approved without change	Extension without change of a currently approved collection	2017-09-28
201407-3220-004 Approved without change	Revision of a currently approved collection	2014-08-01
201203-3220-001 Approved without change	Extension without change of a currently approved collection	2012-03-30
200901-3220-002 Approved without change	Revision of a currently approved collection	2009-01-28
200511-3220-004 Approved without change	Revision of a currently approved collection	2005-11-28
200504-3220-001 Approved without change	Extension without change of a currently approved collection	2005-04-04
200201-3220-003 Approved without change	Extension without change of a currently approved collection	2002-01-29
199811-3220-001 Approved without change	Revision of a currently approved collection	1998-11-20
199506-3220-005 Approved without change	Revision of a currently approved collection	1995-06-23
199307-3220-001 Approved with change	No material or nonsubstantive change to a currently approved collection	1993-07-12
199304-3220-002 Approved without change	Extension without change of a currently approved collection	1993-04-08
199205-3220-002 Approved without change	Revision of a currently approved collection	1992-05-01
199101-3220-001 Approved without change	Revision of a currently approved collection	1991-01-08
198710-3220-001 Approved without change	Extension without change of a currently approved collection	1987-10-02
198409-3220-004 Approved without change	Revision of a currently approved collection	1984-09-26
198209-3220-001 Approved without change	Extension without change of a currently approved collection	1982-09-20
198105-3220-009 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-05-28
198103-3220-017 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-03-21
198102-3220-049 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-02-28
198011-3220-005 Approved with change	No material or nonsubstantive change to a currently approved collection	1980-11-15
198008-3220-005 Approved with change	No material or nonsubstantive change to a currently approved collection	1980-08-28
197908-3220-004 Approved without change	Revision of a currently approved collection	1979-08-17
197907-3220-007 Approved without change	Reinstatement without change of a previously approved collection	1979-07-31
197405-3220-001 Approved without change	New collection (Request for a new OMB Control Number)	1974-05-15

OMB Details

Supplemental Information on Accident and Insurance

Federal Enterprise Architecture: Litigation and Judicial Activities - Resolution Facilitation

Form SI-1C (04-17)	Supplemental Information on Accident and Insurance	Paper Only	Form and instruction
Form ID-30K (05-17)	Notice to Request Supplemental Information on Injury or Illness	Paper Only	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.