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 Claim for Sickness Benefits (Form SI-3)
 Home
          Sickness Benefits for Railroad Employees
          Instructions for Completing Forms
          Claim for Sickness Benefits (Form SI-3)
 Topics
    

      
              Introduction
          Qualification Requirements
          Amount and Duration of Benefits
          Eligibility Requirements
          Medical Statements
          Sick Pay and Supplemental Sickness Benefits
          Disqualifications
          Benefit Reductions
          Personal Injury Settlements
          Reconsideration and Waiver
          When Sickness Benefits are Taxable
          Instructions for Completing Forms
                                General Instructions
          Important Informtion
          Application for Sickness Benefits (Form SI-1a)
          Statement of Sickness (Form SI-1b)
          Statement of Authority to Act for Employee (Form SI-10)
          Claim for Sickness Benefits (Form SI-3)
          Notices
          Checking Your Benefits by Telephone
          Important Reminders 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 (X, E, P, O) to show whether you want to claim benefits for the day (X); or whether you worked (E), received vacation pay, holiday pay, or other pay from your employer (P); or do not want to claim benefits for some other reason (O).

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 that 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.

**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 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.
        ‹ Statement of Authority to Act for Employee (Form SI-10) | 
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 Last updated: 06/20/2017