Form Si-10 - Application For Sickness Benefits - Railroad Retirement Board, United States Of America
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1
2
3
4United States of America
Form Approved
Railroad Retirement Board
OMB No. 3220-0039
Application for Sickness Benefits
Identifying Information
Section A
2. Social Security Number
1. Employee’s Name (First, Middle Initial, and Last)
–
–
4. Date of Birth
3. Employee’s Street Address, City, State and ZIP Code
5. Sex
J
(Including Apartment Number)
Month
Day
Year
Male
J
Female
6. Telephone Number (Include Area Code)
(
)
Infirmity and Employment Information
Section B
7. Date You Became Sick or Injured
8. Date You Last Worked for a Railroad
9. Last Railroad Employer (Name of Company)
10. Location of Last Railroad Employment (City/State)
11. Last Railroad Occupation
12. Department
13.
If you worked for a nonrailroad employer after the date shown in Item 8, complete Items A, B, and C, below. Otherwise, go to Item 14.
A. Last Nonrailroad Employer (Name of Company)
B. Last Occupation After Railroad Work
C. Date Last Worked After Railroad Work
Accident and Insurance Information
Section C
J
J
14. Are you applying for sickness benefits because you were injured at work or have a work-related illness?
Yes
No
15. Have you filed or do you expect to file a lawsuit or claim against any person or company for personal injury?
J
J
Yes - Complete Items A-D, below
No - Go to Item 16
A. Furnish the name and complete address of the person or company.
Name
Address
City, State, ZIP Code
B. Give the place where the injury occurred.
J
J
C. Were you injured in an automobile accident?
Yes
No - Go to Item 16
D. If you were injured in an automobile accident, provide information about all the vehicles, other than your own, that were
involved in the accident that caused your injury. Information about your vehicle and insurance company is not needed. If you
need more space attach a separate sheet of paper.
Owner of Car (other vehicle)
Driver (other vehicle)
Name
Name
Address
Address
City, State, ZIP Code
City, State, ZIP Code
Insurance Company (other vehicle)
Policy Information (other vehicle)
Name
Policy Number
Address
Claim Number
City, State, ZIP Code
Continued on Reverse Side
SI-1a (03-12)
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