ID-30D, Request for Information on Injury or Illness

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

OFFICE HOURS: 9:00 AM TO 3:30 PM
MONDAY THROUGH FRIDAY

CURRENT

TOLL-FREE NUMBER: 1-877-772-5772

In reply refer to
Date of Injury:

When you applied for sickness benefits because of the above referenced injury or illness, you
indicated that you had filed a claim or may seek damages from a liable party as a result of your
infirmity. Please provide the information requested on the enclosed Form ID-30K concerning your
claim against the person or company you hold responsible. Return your reply in the enclosed
envelope. A prompt response is greatly appreciated.
Your Policy Number:
Your Claim Number:
The information requested on the enclosed Form ID-30K is needed in connection with your
application for sickness benefits for your injury/illness of
. The Railroad Retirement Board’s
authority for requesting this information is section 5(b) and 12(o) of the Railroad Unemployment
Insurance Act (RUIA). Because you are required to provide this information under section 9(a) of
the RUIA, failure to complete and return the form could result in a fine or imprisonment or both.
Sincerely,

Enclosures

ID-30D (04-06)