SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefit

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0036

CURRENT

REPORT OF PAYMENTS TO EMPLOYEE CLAIMING SICKNESS BENEFITS UNDER
THE RAILROAD UNEMPLOYMENT INSURANCE ACT
NAME -

SS NO. -

DATE OF INJURY -

SECTION 12(o) OF THE RAILROAD UNEMPLOYMENT INSURANCE ACT:
'"Benefits payable to an employee with respect to days of sickness shall be payable regardless of the liability of any person to
pay damages for such infirmity. The Railroad Retirement Board (RRB) shall be entitled to reimbursement from any sum or
damages paid or payable to such employee or other person through suit, compromise, settlement, judgment, or otherwise on
account of any liability (other than a liability under a health, sickness, accident or similar insurance policy) based upon such
infirmity, to the extent that it will have paid or will pay benefits for days of sickness resulting from such infirmity. Upon notice to
the person against whom such right or claim exists or is asserted, the RRB shall have a lien upon such right or claim, any
judgment obtained thereunder, and any sum or damages paid under such right or claim, to the extent of the amount to which
the RRB is entitled by way of reimbursement."
NOTICE: The RRB's authority for requesting information about any sum or damages, pay for time lost, or workers'
compensation paid or payable to a railroad employee because of the employee's infirmity is section 5(b) and section 9(a) of
the Railroad Unemployment Insurance Act.
1. DAMAGES (No pay for time lost), Paid by Employer or Other Party
If any sum or damages are paid or payable to the employee or other person on account of any liability based on infirmity of
the above-named employee, and such sum or damages include pay for time last, complete the following:
Net amount of settlement* (not including amount of any expenses shown on the next line):
Amount of employee's medical, hospital, and legal
expenses in connection with this injury, if known:

$

Date of
settlement:

$

2. DAMAGES INCLUDING PAY FOR TIME LOST, Paid by Employer
If any sum or damages are paid or payable to the employee or other person on account of any liability based on infirmity
of the above-named employee, and such sum or damages include pay for time lost, complete the following:
Net amount of settlement* (not including amount of any expenses shown on the next line):
Amount of employee's medical, hospital, and legal
expenses in connection with this injury, if known:
Amount of pay for time lost $

$

$

Period to which applicable: From

To

Date of settlement:
3. PAY FOR TIME LOST, Paid by Employer
If only pay for time lost has been paid or is payable, complete the following:
Amount of pay for time lost:

$

Date of payment (if paid):

Period to which applicable: From

To
4. WORKERS' COMPENSATION

Has workers' compensation been paid, is it being paid, or will it be paid for disability?
If "Yes," is it for permanent total or temporary total? Yes
No
If for permanent total or temporary total, complete the following:
Amount paid or payable:
$
Per (week, month, etc.):
Payment beginning date:

Yes

No

Date first payment made:

Payment ending date (if known):
*If amount exceeds
$50,000, enter "In excess
of $50,000."

Name of Employer or Other Person
By
Title

SI-5 (12-93)