ID-3S (Internet) ( Request for Lien Information; Report of Settlement

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PROPOSED
ID-3S (INTERNET)

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ERS Login Screen

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ERS Menu Screen (New Items)

Form ID-3s will appear
here for users.

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United States of America
Railroad Retirement Board
Form ID-3s (xx-xx)

Form Approved
OMB No. 3220-0036

REQUEST FOR LIEN INFORMATION – REPORT OF SETTLEMENT

RRB USE ONLY

FOR RAILROAD USE ONLY
Click to read the Paperwork Reduction Act Notice
and Employer Instructions
1. Employee’s Name:
3. Date of Injury

R

2. SS Number:

4. Information
Only
Yes

11. Payor Code

No

5. Return to
Work

6. Settled

Yes

Yes

No

7. Pay for Time Lost

No

From

9. Employer Remarks

To

8. Amount
Protected &
Amount of
Settlement

12. Billing Doc
ID

13. Lien
Amount

14. Final
Yes

No

15. Remarks

10. Railroad:

Telephone:

16. Representative:

Name of Requestor:
Date:
Date Returned:
Notices: The Railroad Retirement Board’s (RRB) completed reply is confirmation of the amount due under section 12(o) of the Railroad Unemployment Insurance
Act.
Important: A subsequent report is required if you make a payment to the employee and this request is for “Information Only.” The subsequent report is needed to
determine the correct amount of reimbursement due the RRB, to prevent additional benefit payments and to trigger the release of a billing statement for the
amount due. Billing Document ID numbers are provided upon request, but only for claims which have been settled, i.e., cases in which Item 4 is checked “No.”
AMOUNTS DUE THE RRB UNDER SECTION 12(O) MUST BE RECEIVED WITHIN 30 DAYS AFTER THE DATE OF PAYMENT TO THE EMPLOYEE.
AMOUNTS THAT ARE NOT PAID WITHIN 30 DAYS ARE SUBJECT TO INTEREST CHARGES FROM THE DATE OF PAYMENT.
Submit

Save And Return

Print

Reset Record

Exit/No Action

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ERS Menu (Completed Items)

Form ID-3s will appear here for
users when completed.

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PAPERWORK REDUCTION ACT NOTICE
The Railroad Retirement Board is authorized to collection the information under section 5(b) of
the Railroad Unemployment Insurance Act (RUIA). The information is needed to determine the
amount of sickness benefits reimbursable under section 12(o) of the RUIA. Because you are
required to provide this information under section 9(a) of the RUIA, failure to complete and
submit this form could result in a fine or imprisonment or both.
We estimate it takes an average of 3 minutes to complete this form, including the time 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 completion time, to Chief of Information Resources Management, U.S. Railroad
Retirement Board, 844 N. Rush St, Chicago, IL 60611-2092.

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EMPLOYER INSTRUCTIONS

1. Enter the employee’s first initial, middle initial, and last name. Do not enter a
partial name.
2. Enter the employee’s social security number.
3. Enter the earliest date of occurrence of the injury.
4. Click “Yes” if you are making an informational inquiry on this case and no payment
will be issued to the employee at this time. Check “No” if a payment will be issued to
the employee once you receive a reply from the RRB. Note that a second report
is required if you make a payment to the employee and your first request was
for “Information Only.” Your second report is required to prevent additional
benefit payments to the employee and to trigger the release of a billing
statement for the amount due the RRB under section 12(o).
5. Click the appropriate box to indicate if the employee has returned to work. If the
employee has returned to work, enter the date returned to work. Otherwise, go to
item 8.
6. If settlement documents have been signed and a settlement concluded, click “Yes”
and provide the date of the settlement. If the settlement has been agreed upon, but
documents have not yet been signed, or if settlement negotiations are proceeding,
click “No” and submit the form.
7. If any part of the settlement is apportioned to pay for time lost, show the exact
months or other time period to which pay is allocated.
8. Complete only if a settlement has been made. Enter the amount withheld from
the settlement for reimbursement to the RRB and the gross amount of the
settlement. Information about the gross settlement amount is used to compute the
period of time after the date of the settlement for which benefits are not payable on
the basis of the same infirmity. Benefits are payable only after the amount of the
benefits otherwise payable exceed the amount of the settlement. If the settlement
exceeds $50,000, indicate only “In excess of $50,000.”
9. Enter any remarks concerning the employee’s settlement.
Note: If the lien amount shown in Item 13 is “Not Final,” the amount is valid for
settlement and reimbursement purposes only if you inform the RRB within 5 days that
settlement has been made. Otherwise, additional benefits may be made to the
employee. All settlements and final judgments must be reported to the RRB in writing
within 5 days of the date of settlement or judgment.