General Instructions

Complete all items by printing neatly in ink or by using a typewriter. Do not skip any items unless directed to do so. If you need more space to answer a question, enclose a separate sheet of paper. Be sure to sign your name and date the form before mailing. Have your doctor complete Form SI-1b, Statement of Sickness. Do not separate the forms.

Read the following instructions carefully before completing your application. If your application is not completed correctly, your benefits may be delayed. Contact your local RRB office if you have questions or need assistance in completing the form.

Important Information

The completed and signed form must be received by an RRB office within 10 days of the first day for which you want to claim benefits. You may lose benefits if your application is filed late. If the form is late, enclose an explanation.

Once your application has been processed, a claim form will be mailed to you for completion. You must complete and return the claim to the RRB office whose address appears on the claim. A notice of the claim will be sent to your employer. A claim for the next 14-day period will be mailed to you on or about the last day of the period covered by the claim.

Application for Sickness Benefits (SI-1a)

Section A - Identifying Information —

Items 1 - 6 are self-explanatory.

Section B - Infirmity and Employment Information —

Item 7 - is self-explanatory.

Item 8 - Enter the date you last worked for your last railroad employer before you became sick and unable to work.  For example, if you worked on 12/31 and became sick on 1/1, would enter 12/31 as the date last worked.

Item 9 and 10 - are self-explanatory.

Item 11 - Enter the title of your job. For example, "Road Brakeman."

Item 12 - Enter the department of the railroad in which you work. For example, "Train and Engine Service."

Item 13A-C - Complete this item if you worked for a non-railroad employer or were self-employed after the last day you worked for a railroad employer.

• Item 13A - Enter the name of the company for which you worked most recently. For example, "Acme Accounting."
• Item 13B - Enter the title of your job. For example, "Accountant."
• Item 13C - Enter the date you last worked outside the railroad industry before you became sick and unable to work.  For example, if you last worked on 12/31 and became sick on 1/1, you would enter 12/31 as the date last worked.

Section C - Accident and Insurance Information —

Item 14 is self-explanatory.

Item 15 - Check "Yes" if you filed or expect to file a lawsuit or claim against any person or company for personal injury.

Item 15A is self-explanatory.

Item 15B - Enter the location where your injury or illness occurred.  For example, "Hwy 51/County Rd 12, Toledo, Ohio."

Item 15C - Check "Yes" if you were injured in a automobile accident.

Item 15D - If you checked "Yes" in Item 15c, complete the following items about all the vehicles involved in the accident, other than your own.

Owner of Car - Enter the complete name and address of the owner of the other vehicle involved in the accident.

Driver - Enter the complete name and address of the driver of the other car or vehicle involved in the accident.  If more than one other vehicle was involved, give information for all vehicles on a separate sheet of paper.

Insurance Company - Enter the complete name and address of the insurance company of the owner of the other vehicle involved in the accident.

Policy Information - Enter the policy number of the insurance policy held by the owner of the other vehicle and the claim number assigned by the insurance company, if you know it.

Section D - Claim for Sickness Benefits Information —

Your first sickness benefit claim is Items 16 through 20 on your SI-1a, Application for Sickness Benefits. After your application and claim have been received and processed, your next sickness claim will be mailed to you.

Item 16 - is self-explanatory.

Item 17 - Check "Yes" if you want to claim every day from the date you entered in Item 16 through the current date as a day of sickness. Check "No" if you do not wish to claim every day. Remember that you cannot claim benefits for any day on which you worked or otherwise earned wages, holiday pay, vacation pay, sick pay (excluding supplemental sickness benefits) or other pay. This includes pay from full-time and part-time work in either railroad or nonrailroad employment, and from self-employment. You may claim rest days on which you were sick or injured and for which you do not receive pay from your employer.

Item 18 - If you checked "No" in Item 17, enter the dates that you do not wish to claim.

Item 19 - If you have recovered from your infirmity and have returned to work, enter the date you returned to work. However, if you worked one or more days, but then continued to be unable to work, do not enter a date in this item. For example, if you attempted to return to work but found that you were not able to continue working, indicate the days you worked and received wages in Item 18, but do not enter a date in Item 19.

Item 20A-C - Each item must be checked "Yes" or "No" to indicate the type of payments, if any, that you have received or will receive for days in the claim period. Also furnish the dates and/or other information requested about  the payment. The types of payments are explained below.

• Wages — Payments that you receive from your railroad employer, from a nonrailroad employer or your own business for services you performed. Benefits are not payable for any day for which you receive wages.
  
  Regular Wages — Pay for time worked, including full-time and part-time work.
  
  Vacation Pay — Pay for scheduled or assigned vacation days. Vacation pay does not include "pay in lieu of vacation." If you don't know if the payment you received was "pay in lieu of vacation," check with your payroll office before completing this item.
  
  Holiday Pay — Pay from your employer for a holiday.
  
  Military Reservist Pay — Wages paid to you by the Federal Government based on your military service.
  
  Wage Continuation Pay — Salary or wages paid by your railroad employer when you have been injured on-duty. The purpose of the payments is to continue your wage or salary, not to supplement RRB benefits. The payments are subject to normal payroll deductions.
  
  Earnings from Self-Employment — Payment for services performed.
  
  Sick Pay from Your Employer — A continuation of all or part of your wages while you are unable to work. The term "Sick Pay" does not include supplemental sickness benefits. Click here for an explanation of supplemental sickness benefits.
   
•  Governmental Payments — Annuities or other payments made to you by a county, city, state or Federal Government. If you are receiving a governmental payment, check the appropriate box and give the beginning date, the gross amount and the frequency of the payment. For an explanation of how governmental payments affect the payment of sickness benefits by the RRB, see the section Benefit Reductions.
  
  Sickness or Unemployment Benefits Under Any Other Law — Benefits paid to you on account of sickness or unemployment by a county, city or state government, or by another Federal agency.
  
  Social Security Benefits — Benefits paid to you by the Social Security Administration, excluding supplemental security income payments (SSI).
  
  Railroad Retirement or Disability Annuity — Monthly payments made to you by the RRB based on your age and railroad service or on disability. An RRB annuity under the Railroad Retirement Act is not the same as RRB sickness benefits.
  
  Military Retirement Pay — An annuity, pension or retainer pay paid to you by the Federal Government based on your military service.
  
  Worker's Compensation — Disability payments made to you under a state law when you have been injured on the job.
  
  Retirement Payments Under Another Law — An annuity or pension paid to you by a county, city, state or Federal Government.
   
• Other Payments — If you are receiving some type of other payment, check the appropriate box and give the date of the payment and who made payment to you.
  
  Settlement or Damages for Personal Injury — A payment received as a result of a judgment or the settlement of a personal-injury claim against your railroad employer or another party that you held liable for your injury or illness.
  
  Advances — A payment received in anticipation of a settlement of a personal injury claim against your railroad employer.
  
  Separation Allowance (Buyout, Severance Pay) — A payment received when you resign in return for a specified sum of money. The payments are also referred to as "buyouts" or "severance pay." Payment may be made in a lump sum or installments in return for your resignation.

Item 21 is self-explanatory.

SECTION E - Direct Deposit Information —

Item 22 - Federal law requires the RRB to pay your benefits by Direct Deposit. With Direct Deposit, your benefit payments are sent directly to your bank, savings and loan, credit union or other financial institution. Payments are sent electronically, which saves money by eliminating the need to print and mail checks.

Direct Deposit has many advantages. Direct Deposit payments are generally available 2 to 5 days sooner than payment by check. You do not have to worry about a check being lost, stolen or misplaced, and you can be away from home without the worry of a check sitting unprotected in your mailbox. There is no need to wait for mail delivery of a check or to make a special trip to your bank.

To provide the information we need to correctly deposit your benefit payments, attach a voided personal check to your application. If you do not attach a voided personal check, call your financial institution for the information you need to complete this item.

If you change your bank or your account while claiming benefits, be sure to submit a new voided personal check to the RRB to establish Direct Deposit to your new account. Do not close your old account until you receive the first RRB payment in your new account.

There are some exceptions that allow payments to be made by check:

• If receiving your payments by Direct Deposit would cause you a hardship because you have a physical or mental disability or because of a geographic, language, or literacy barrier; or
   
• if you do not have a checking or savings account at a bank or other financial institution; or
   
• if receiving your payments electronically would cause you a financial hardship because it would cost you more than receiving your payments by check.

If any of these apply to you, check the box in Item 22F.

SECTION F - Certification and Signature —

Item 23 - By signing and dating this item you certify that the information contained on the form is true, correct, and complete.

If the sick or injured employee is unable to sign in Item 23, the person completing the application should sign in Item 23, and complete Form SI-10, Statement of Authority to Act for Employee.

Statement of Sickness (Form SI-1b)

The SI-1b, Statement of Sickness must be completed by your doctor or other qualified medical provider (see the section Medical Statements). If possible, have your doctor complete the statement while you are at his or her office, rather than leaving the form for completion. If you must leave the form for completion, explain to your doctor that the form is needed in order for you to receive bi-weekly benefit payments and that the form must be received by the Railroad Retirement Board within 10 days of the first day you became sick or injured or you may lose benefits.

Do not separate the SI-1b, Statement of Sickness from your SI-1a, Application for Sickness Benefits.

Statement of Authority to Act for Employee (Form SI-10)

Completion of Form SI-10, Statement of Authority to Act for Employee, is not required for an employee who can sign papers or can sign by a mark and who understands transactions related to his or her application for benefits. Completing Form SI-10, gives the signer the authority to sign any claim form on behalf of the employee.

Section 1 - Statement of Individual Acting for Employee

This section is to be completed by the individual who signed the SI-1a, Application for Sickness Benefits and who will act on behalf of the employee. Enter the employee's name, social security number, and address. Briefly explain why you believe the employee is incapable, and enter your relationship to the employee. If you are not related to the employee by blood or marriage, state your relationship and explain why no relative is acting for the employee. For example, an employee's foreman might explain: "My relationship to the employee is his foreman. He has no immediate family."

When signing claim forms use your full name, and beneath your signature write "On behalf of" and the employee's full name.

Section 2 - Statement of Employee's Doctor

Have the employee's medical doctor complete this section.

Claim for Sickness Benefits (Form SI-3)

The following instructions are for claim forms mailed to you by the RRB. Read the instructions carefully before completing your claim forms. Failure to complete your claim correctly could delay the payment of benefits.

Important Information
Claims for days after your first claim which is included on the SI-1a, Application for Sickness Benefits, will be mailed to you for as long as you remain unable to work and eligible for benefits. You must complete and return each claim promptly or you may lose benefits. The time for filing a claim, including time for mailing, is limited to 30 days from the last day of the claim period, or 30 days from the date the claim form was mailed to you, whichever is later.

If you return to work and stop claiming benefits, but become sick or injured again later in a benefit year, you must file a new SI-1a, Application for Sickness Benefits.

Item 1 - This item shows the days in the claim period. Below each day of the claim period, you must enter the correct letter code to show whether you want to claim benefits for the day, or whether you worked, received vacation pay, holiday pay, or other pay from your employer, or do not want to claim benefits for some other reason.

Remember that you cannot claim benefits for any day on which you worked or otherwise earned regular wages, vacation pay, holiday pay, military reservist pay, wage continuation pay, sick pay (excluding supplemental sickness benefits), or other pay. This includes pay from full-time and part-time work in either railroad or nonrailroad employment.

This link provides an example of how the boxes are to be completed.

Use the following letter codes to show whether you are claiming benefits for the days in the claim period.

X - Enter an "X" if you did not work on the day, will not receive any type of pay for the day, and were unable to work because of injury or illness on the day. Any day you mark with an "X" is considered to be a day of sickness for which you are claiming benefits.

Use an "X" to claim normal rest days on which you were unable to work. Do not claim your rest days if you were able to work, worked, or otherwise received pay from either a railroad or nonrailroad employer for the days.

E - Enter an "E" if you were employed either full time or part time on the day. Include work for either a railroad or nonrailroad employer, and any self-employment.

P - Enter a "P" for any day that you were not employed, but will receive payment from a railroad or nonrailroad employer. This includes such payments as vacation pay, holiday pay, wage continuation pay, sick pay (excluding supplemental sickness benefits), daily wage guarantee payments, and pay for time lost.

Do not enter "P" for days you receive payments under a supplemental sickness benefit plan paid for or financed by your employer, such as benefits paid by Trustmark Insurance Company or Provident Life Insurance Company. Such payments are normally paid in addition to your sickness benefits from the RRB. For an explanation of the difference between regular sick pay, which you must report, and supplemental sickness benefits, see the back of your claim form or the section Sick Pay and Supplemental Sickness Benefits on page 4 of this booklet.

O - Enter an "O" for days on which you did not work and did not receive any type of payment, but which you do not wish to claim for some other reason.

Item 2A - If you have recovered from your infirmity and have returned to work, answer Item 2A "YES" and enter the date you returned to work in item 2B. If you attempted to return to work but found that you were not able to continue working, answer Item 2A "NO" and enter and "E" in Item 1 for any day you worked and received wages. Do not enter a return-to-work date in item 2B.

Item 3 - This item is pre-filled with the name and address of an RRB office. Mail your completed claim to that office.

Item 4 - This item is pre-filled with your name and address. If necessary, show corrections to your name and address in the box.

Item 5 - See Item 20 on page 6 of this booklet for instructions on completing this item.

Item 6 - By signing and dating this item you certify that the information contained on your claim form is true and complete. Do not complete and sign the claim form before the last day of the claim period. If your claim is received by the RRB before the last day of the claim period, benefits due you may be delayed or denied.