Supplemental Information on Accident and Insurance

Documents and Forms

Document Name Document Type
Form SI-1C (04-17) Supplemental Information on Accident and Insurance Form and Instruction
SI-1C (04-17) Supplemental Information on Accident and Insurance Form SI-1c (04-17).pdf Form and Instruction
SI-1C (04-17) Supplemental Information on Accident and Insurance Form SI-1c (04-17).pdf Form and Instruction
ID-30K (05-17) Notice to Request Supplemental Information on Injury or Form ID-30K (05-17).pdf Form
ID-30K (05-17) Notice to Request Supplemental Information on Injury or Form ID-30K (05-17).pdf Form
Form ID-30D (04-06).pdf ID-30D, Request for Information on Injury or Illness IC Document
Form ID-30D (04-06).pdf ID-30D, Request for Information on Injury or Illness 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-1C (04-17)	Supplemental Information on Accident and Insurance	Form SI-1c (04-17).pdf		No		Paper Only
Form	ID-30K (05-17)	Notice to Request Supplemental Information on Injury or Illness	Form ID-30K (05-17).pdf		No		Paper Only

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records
Title: RRB-21, Railroad Unemployment and Sickness Insurance Benefit System	FR Citation: 78 FR 58874

Number of Respondents: 914	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	914	-886	1,800
Annual IC Time Burden (Hours)	76	-74	150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
ID-30D, Request for Information on Injury or Illness	Form ID-30D (04-06).pdf	09/12/2017

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