Supplemental Information on Accident and Insurance

OMB: 3220-0036

IC ID: 187866

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0036 can be found here:

Documents and Forms

Document Name Document Type
Form SI-5 (12-93) Supplemental Information on Accident and Insurance Form and Instruction
SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefit Form SI-5 (12-93).pdf Form and Instruction
ID-3S (03-09) Request for Lien Information; Report of Settlement Form ID-3s (03-09).pdf Form and Instruction
ID-3S-1 (03-09) Lien Information Under Section 12(o) of the RUIA Form ID-3S-1 (03-09).pdf Form and Instruction
ID-3U (03-09) Request for Section 2(f) Information Form ID-3u (03-09).pdf Form and Instruction
ID-30K-1 (03-02) Request for Supplemental Information on Injury or Illnes Form ID-30K-1 (03-02).pdf Form and Instruction
ID-3S (Internet) ( Request for Lien Information; Report of Settlement Form ID-3S (Internet) proposed.pdf secure.rrb.gov/ERSNet/login.aspx Form and Instruction
ID-3U (Internet) ( Request for Section 2(f) Information Form ID-3U (Internet) proposed.pdf secure.rrb.gov/ERSNet/login.aspx Form and Instruction
Form ID-30B-1 (02-99).pdf Notice of Lien Transmittal Letter IC Document
Form ID-30B-2 (02-99).pdf Notice of Lien Transmittal Letter IC Document
Form ID-30B (08-12).pdf Notice of Lien Transmittal Letter IC Document
Program Letter(2-06) E-Mail requests.pdf Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements IC Document
Form ID-30D-1 (04-06).pdf ID-30D-1, Request for Information on Injury or Illness IC Document
Form ID-3S (Internet) Screen Descriptions.pdf ID-3S Internet Screen Descriptions IC Document
Form ID-3U (Internet) Screen Descriptions.pdf ID-3U Internet Screen Descriptions IC Document
Program Letter for ERs under 2(f) & 12(o).pdf Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f) IC Document
Draft Program Letter re Internet ID-3S and ID-3U.pdf Draft Program Letter re Internet ID-3S and ID-3U IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Information on Accident and Insurance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 341 20 CFR 340

Information Collection Instruments:

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 (03-09)	Lien Information Under Section 12(o) of the RUIA	Form ID-3S-1 (03-09).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-30K-1 (03-02)	Request for Supplemental Information on Injury or Illness - 3rd party	Form ID-30K-1 (03-02).pdf		No		Paper Only
Form and Instruction	ID-3S (Internet) (proposed)	Request for Lien Information; Report of Settlement	Form ID-3S (Internet) proposed.pdf	https://secure.rrb.gov/ERSNet/login.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	ID-3U (Internet) (proposed)	Request for Section 2(f) Information	Form ID-3U (Internet) proposed.pdf	https://secure.rrb.gov/ERSNet/login.aspx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records
Title: RRB-21, Railroad Unemployment and Sickness Benefit System	FR Citation: 75 FR 43725

Number of Respondents: 1,325	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,272	2,500	-9,010	16,782
Annual IC Time Burden (Hours)	516	125	-451	842
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Notice of Lien Transmittal Letter	Form ID-30B-1 (02-99).pdf	01/26/2009
Notice of Lien Transmittal Letter	Form ID-30B-2 (02-99).pdf	01/26/2009
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(2-06) E-Mail requests.pdf	01/27/2009
ID-30D-1, Request for Information on Injury or Illness	Form ID-30D-1 (04-06).pdf	07/16/2014
ID-3S Internet Screen Descriptions	Form ID-3S (Internet) Screen Descriptions.pdf	07/18/2014
ID-3U Internet Screen Descriptions	Form ID-3U (Internet) Screen Descriptions.pdf	07/18/2014
Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f)	Program Letter for ERs under 2(f) & 12(o).pdf	07/25/2014
Draft Program Letter re Internet ID-3S and ID-3U	Draft Program Letter re Internet ID-3S and ID-3U.pdf	08/01/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.