Supplemental Information on Accident and Insurance

OMB: 3220-0036

IC ID: 187866

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
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 (03-09) Request for Lien Information; Report of Settlement Form ID-3S (03-09).pdf Form and Instruction
ID-3S-1 (08-17) Lien Information Under Section 12(o) of the RUIA Form ID-3S1 (08-17).pdf Form and Instruction
ID-3S-1 (08-17) Lien Information Under Section 12(o) of the RUIA Form ID-3S1 (08-17).pdf Form and Instruction
ID-3U (03-09) Request for Section 2(f) Information Form ID-3u (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-3S (Internet) ( Request for Lien Information; Report of Settlement Form ID-3S (Internet) (09-14) Screens.pdf secure.rrb.gov/ERSNet/login.aspx Form and Instruction
ID-3S (Internet) ( Request for Lien Information; Report of Settlement Form ID-3S (Internet) (09-14) Screens.pdf secure.rrb.gov/ERSNet/login.aspx Form and Instruction
ID-3U (Internet) ( Request for Section 2(f) Information Form ID-3U (Internet) (09-14) Screens.pdf secure.rrb.gov/ERSNet/login.aspx Form and Instruction
ID-3U (Internet) ( Request for Section 2(f) Information Form ID-3U (Internet) (09-14) Screens.pdf secure.rrb.gov/ERSNet/login.aspx Form and Instruction
ID-3S (xx-xx) Request for Lien Information: Report of Settlement Form ID-3S (Paper) - Proposed (xx-xx).pdf Form and Instruction
ID-3S (xx-xx) Request for Lien Information: Report of Settlement Form ID-3S (Paper) - Proposed (xx-xx).pdf Form and Instruction
ID-3U Request for Section 2(f) Information Form ID-3U (Paper) - Proposed (xx-xx).pdf Form and Instruction
ID-3U Request for Section 2(f) Information Form ID-3U (Paper) - Proposed (xx-xx).pdf Form and Instruction
Form ID-30B-1 (08-17).pdf Notice of Lien Transmittal Letter IC Document
Form ID-30B-1 (08-17).pdf Notice of Lien Transmittal Letter IC Document
Form ID-30B-2 (08-17).pdf Notice of Lien Transmittal Letter IC Document
Form ID-30B-2 (08-17).pdf Notice of Lien Transmittal Letter IC Document
Form ID-30B (08-12).pdf Notice of Lien Transmittal Letter IC Document
Form ID-30B (08-12).pdf Notice of Lien Transmittal Letter IC Document
Program Letter (06-05) for E-Mail requests.pdf Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements IC Document
Program Letter (06-05) for 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-30D-1 (04-06).pdf ID-30D-1, Request for Information on Injury or Illness IC Document
Program Letter (07-02) for ERs under 2(f) & 12(o).pdf Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f) IC Document
Program Letter (07-02) for ERs under 2(f) & 12(o).pdf Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f) 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 (08-17)	Lien Information Under Section 12(o) of the RUIA	Form ID-3S1 (08-17).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-3S (Internet) (09-14)	Request for Lien Information; Report of Settlement	Form ID-3S (Internet) (09-14) Screens.pdf	https://secure.rrb.gov/ERSNet/login.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	ID-3U (Internet) (09-14)	Request for Section 2(f) Information	Form ID-3U (Internet) (09-14) Screens.pdf	https://secure.rrb.gov/ERSNet/login.aspx	Yes	Yes	Fillable Fileable
Form and Instruction	ID-3S (xx-xx)	Request for Lien Information: Report of Settlement	Form ID-3S (Paper) - Proposed (xx-xx).pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	ID-3U	Request for Section 2(f) Information	Form ID-3U (Paper) - Proposed (xx-xx).pdf		Yes	Yes	Fillable Fileable Signable

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: 79 FR 58874

Number of Respondents: 9,156	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 39 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	9,156	2,056	7,100
Annual IC Time Burden (Hours)	462	104	358
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Notice of Lien Transmittal Letter	Form ID-30B-1 (08-17).pdf	09/22/2017
Notice of Lien Transmittal Letter	Form ID-30B-2 (08-17).pdf	09/22/2017
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 (06-05) for E-Mail requests.pdf	09/12/2017
ID-30D-1, Request for Information on Injury or Illness	Form ID-30D-1 (04-06).pdf	07/16/2014
Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f)	Program Letter (07-02) for ERs under 2(f) & 12(o).pdf	09/12/2017

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