SI-1a, Application for Sickness Benefits

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0039

Application for Sickness Benefits
Section A
!

Identifying Information

1.

Employee's Name (First, Middle Initial, and Last)

3.

Employee's Street Address, City, State and ZIP Code
(Including Apartment Number)

Section B

5. Sex
>----::-::--:--r---'-'-=---r----=::-----i

0

Male

o Female

Infirmity and Employment Information

7. Date You Became Sick or Injured _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
8.

Date You Last Worked for a Railroadu-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

9.

Last Railroad Employer (Name ofCompany) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

10. Location of Last Railroad Employment (('itu/~~t"t,"'l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11. Last Railroad Occupation _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

12. Departroent _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
13. If you worked for a nonrailroad employer after the date shown in Item 8, complete Items A, B, and C, below. Otherwise, go to Item 14.
A. Last Nonrailroad Employer (Name o f C o m p a n y ) - - - - - - - - - - - - - - - - - - - - - - - - ­
B. Last Occupation After Railroad W o r k - - - - - - - - - - - - - - - - - - - - - - - - - - - - ­

C. Date Last Worked After Railroad Work

Section C

Accident and Insurance Information

14. Are you applying for sickness benefits because you were injured at work or have a work-related illness? 0 Yes
15. Have you filed or do you expect to file a lawsuit or claim against any person or company for personal injury?
DYes - Complete Items A-D, below
0 No - Go to Item 16
A. Furnish the name and complete address of the person or company.

0

No

Name----------------------------------------------------­
Address-----------------------------------------------------­
City, State, ZIP C o d e - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ­
B. Give the place where the injury occurred. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ­

C. Were you injured in an automobile accident?

DYes

o No - Go to Item 16

D. If you were injured in an automobile accident, provide information about all the vehicles, other than your own, that were
involved in the accident that caused your injury. Information about your vehicle and insurance company is not needed. If you
need more space attach a separate sheet of paper.

Owner of Car other vehicle)

Driver other vehicle

Name

Name

Address

Address

City, State, ZIP Code

City, State, ZIP Code

Insurance Company (other vehicle)

Policy Information (other vehicle)

Name

Policy Number

Address

Claim Number

City, State, ZIP Code
Continued on Reverse Side

SI-la (02-09)

Section 0

Claim for Sickness Benefits Information

16. Enter the earliest date you wish to claim sickness benefits. _ _ _ _ _ _ _ _ _ _ _~~_ _ _ _ _ _ _ _ _ _ __
17. Are you claiming all the days of sickness beginning with the date you entered in Item 16? (Note: You may claim rest days if you
were unable to work and did not receive pay from your employer.)
0 Yes - Go to Item 19 0 No - Go to Item 18
18. Enter any dates that you do not wish to claim. _ .....~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _'--_ _-,.-_ _ _ __
19. Enter the date you returned to work (if applicable). _ _ _ _ __
20. You must complete aU boxes to indicate if you have received or will receive any ofthe following payments for your days ofsickness.
If you check "YES" for any item, be sure to provide the requested information.
A. WAGES (Include Railroad and Ncinrailroad Wages)
YES NO If "YES," show the dates for which you were paid in MonthlDay/Year format below.
0 Regular Wages................. _ _ _ __

0 Vacation Pay ........................~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Holiday Pay .................. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Military Reservist Pay .......... _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0 Wage Continuation Pay ......... _ _ __

0 Earnings from Self-Employment .. _ _ _ __
0 Sick Pay from Your Employer .... _ _ _ .~--=----::-==_:_:_--=---=:--=-.__:_::___c=_=__._:_:__----(but not payments supplementing Railroad Retirement Board (RRB) benefits. See Booklet UB-ll)

o
o
o
o
o
o

o

B. GOVERNMENTAL PAYMENTS (Not RRB Sickness Benefits)
YES NO If "YES," enclose copy of award letter and complete Items 1 - 3 below.
0 Sickness or Unemployment Benefits Under Any Other Law
1. Beginning Date of Payment _ _ _ _ _ __
0 S07ial Securi.ty Benefits. . . .
2. Gross Amount of Payment $
0 R~I~road Re~lrement or DIsabIlIty AnnUIty
3. How often do you receive the-p-a~y~m~e~n~t?~.- - - ­
0 MIlitary RetIrement ~ay
0 WeekIY 0 Monthl 0 Yearly
0 Worker's CompensatIon
DOth r
Y
0 Retirement Payments Under Another Law
e . ------~-------

o
o
o
o

oo

C. OTHER PAYMENTS
YES ~ If "YES," complete Items 1 and 2.
0 Settlement or Damages for Personal Injury
0 Advances
0 Separation Allowance (Buyout, Severance Pay)

o
o

o

L Date of Payment

2. Paid By: _ _ _ _ _ _ _ _ _ _ _ _ __

21. If the date you are submitting this form is more than 30 days after the date you entered in Item 16, answer the following:
A. Why did it take more than 30 days to submit this form? If more space is needed, attach a separate sheet of paper.
B. How did you obtain this fonn? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

C. Who provided this form to you? _ _ _ _ _ _ _ _ _ _ __
D. On what date did you obtain the form? _ _ _ _ _ __
E. Furnish the name aQd title of any person from whom you asked for help in completing and filing the forms.
TITLE

Section E

Direct Deposit Information

22. Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To provide

the information we need to correctly deposit your payments, attach a voided personal check and go to Item 23, or call your
financial institution for the information you need to complete Items A-E. If you do not have a bank account, or receiving your pay­
ments by Direct Deposit would cause you a hardship, go to Item F.
A. Routing Transit Number
C. Account Type:

o Checking

0

I I I I I I I I I

B. Account No. _

..._ _ _ _ _ _ _ __

D. Name of Financial Institution:
Saving

E. Telephone No. (Include Area Code) '--_---"_ _ _ _ _ _ _ _ _ _ __

F. 0 Check this box if ou do not have a checking, or savings account, or if Direct Deposit would cause you a hardship.

Section F

Certification and Signature

23. I waive any "doctor-patient privilege" I may have with respect to the disclosure ofinfonnation concerning the period ofsickness or injury on
which my claim is based. 1certifY that I understand and agree to the requirements in Booklet UB-ll. I know that disqualification and civil and
criminal penalties may be imposed on me for false or fraudulent statements or claims or for withholding infonnation to get benefits from the
RRB. I affinn that the infonnation given on this fonn is true, correct and complete. NOTE: If the sick or injured employee is unable to sign
this fonn, sign your name and complete Section I of the attached Fonn SI-l 0, Statement ofAuthority to Act for Employee.
SIGNATURE
Sl-Ia (02-09)

HAVE YOUR DOCTOR COMPLETE THE AITACHED STATEMENT OF SICKNESS