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Claim for Sickness Benefits Information

Section D

16. Enter the earliest date you wish to claim sickness benefits. _________________________________________________________

17. Are you claiming all the days of sickness beginning with the date you entered in Item 16? (Note: You may claim rest days if you

Yes - Go to Item 19

No - Go to Item 18

were unable to work and did not receive pay from your employer.)

18. Enter any dates that you do not wish to claim. ___________________________________________________________________

19. Enter the date you returned to work (if applicable). _______________________________________________________________

20. You must complete all boxes to indicate if you have received or will receive any of the following payments for your days of sickness.

If you check “YES” for any item, be sure to provide the requested information.

A. WAGES (Include Railroad and Nonrailroad Wages)

YES NO If “YES,” show the dates for which you were paid in Month/Day/Year format below.

J Regular Wages. . . . . . . . . . . .. . . . . ________________________________________________________________

J Vacation Pay . . . . . . . . . . . . . . . . . . ________________________________________________________________

J Holiday Pay . . . . . . . . . . . . . . . . . . ________________________________________________________________

J Military Reservist Pay . . . . . . . . . . ________________________________________________________________

J Wage Continuation Pay . . . . . . . . . ________________________________________________________________

J Earnings from Self-Employment . . ________________________________________________________________

J Sick Pay from Your Employer . . . . ________________________________________________________________

(but not payments supplementing Railroad Retirement Board (RRB) benefits. See Booklet UB-11)

B. GOVERNMENTAL PAYMENTS (Not RRB Sickness Benefits)

YES NO If “YES,” enclose copy of award letter and complete Items 1 - 3 below.

J Sickness or Unemployment Benefits Under Any Other Law

1. Beginning Date of Payment

J Social Security Benefits

2. Gross Amount of Payment $ __________________

J Railroad Retirement or Disability Annuity

3. How often do you receive the payment?

J Military Retirement Pay

Weekly

Monthly

Yearly

J Worker’s Compensation

Other: ________________________________

J Retirement Payments Under Another Law

C. OTHER PAYMENTS

YES NO If “YES,” complete Items 1 and 2.

J Settlement, Judgment or Damages for Personal Injury

1. Date of Payment

J Advances

2. Paid By: __________________________________

J Separation Allowance (Buyout, Severance Pay)

21. If the date you are submitting this form is more than 30 days after the date you entered in Item 16, answer the following:

A. Why did it take more than 30 days to submit this form? If more space is needed, attach a separate sheet of paper.

____________________________________________________________________________________________________ __

B. How did you obtain this form? ____________________________________________________________________________ _

C. Who provided this form to you? ____________________________________________________________________________

D. On what date did you obtain the form? ______________________________________________________________________

E. Furnish the name and title of any person from whom you asked for help in completing and filing the forms.

NAME_______________________________________________________ TITLE ___________________________________

Direct Deposit Information

Section E

Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To provide

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the information we need to correctly deposit your payments, attach a voided personal check and go to Item 23, or call your

financial institution for the information you need to complete Items A-E.

A. Routing Transit Number

B. Account No. __________________________ _ ____

C. Account Type:

D. Name of Financial Institution: _______________________________________ __

J Checking J Saving

E. Telephone No. (Include Area Code) (_______)____________________________

Certification and Signature

Section F

I waive any ”doctor-patient privilege” I may have with respect to the disclosure of information concerning the period of sickness or injury on

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which my claim is based. I certify that I understand and agree to the requirements in Booklet UB-11. I know that disqualification and civil and

criminal penalties may be imposed on me for false or fraudulent statements or claims or for withholding information to get benefits from the

RRB. I affirm that the information given on this form is true, correct and complete. NOTE: If the sick or injured employee is unable to sign

this form, sign your name and complete Section 1 of the attached Form SI-10, Statement of Authority to Act for Employee.

SIGNATURE ______________________________________________________________________ DATE __________________

SI-1a (03-12)

AVE YOUR DOCTOR COMPLETE THE ATTACHED STATEMENT OF SICKNESS

Form Si-10 - Application For Sickness Benefits - Railroad Retirement Board, United States Of America Page 2

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