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UNITED STATES OF AMERICA 1D-308
RAILROAD RETIREMENT BOARD (08-12)
844 N. RUSH STREET
CHICAGO, ILLINOIS 60611-2092

NOTICE OF LIEN

OFFICE OF PROGRAMS SS _NO., NAME, AND ADDRESS
OPERATIONS

OCCUPATION

DATE INJURED DATE LAST WORKED

The individual named above has applied for sickness benefits under the Railroad
Unemployment Insurance Act (RUIA). This letter is notice of the Railroad Retirement
Board's (RRB) Fight to reimbursement of such sickness benefits from any sum payable on
account of liability based on the employee's injury or illness.

Section 12(0) of the RUIA is quoted on the enclosed Form SI-5.. Please note the provisions
of that section concerning the lien which the RRB has when notice such as this letter is
given in a personal injury case. In view of this lien you should see that the RRB is
properly reimbursed if any settlement is made with the individual. Otherwise you may have
to reimburse the RRB. To protect your interest, please follow these instructions:

1. If you have liability insurance, turn this letter over to your insurance company and
let the RRB know the name and address of the insurance company. Further, if you have
any agreement whereby a third party may have assumed liability, make sure that the
third party knows about this notice.

2. If it appears that through legal action or out-of-court settlement, a sum or damages
may become payable for personal injury to the employee, please ask the RRB by letter,
facsimile Form ID-3S, of telephone, how much has been pald in sickness benefits.
Address the inquiry to the Claims Adjustment and Settlement Section at the address
shown above or telephone (312) 751-4820. Ts] aphons inquiries received by 2 P.M,
(Central Time) are normally answered the next business day.

3. If a sum does become payable for persona] injury, make sure that any amount due in
reimbursement for sickness benefits is withheld and paid to the RRB. Regulations
require that you notify the RRB within 5 days of a settlement or j nen and that you
pay the RRB the amount withheld to satisfy the lien within 30 dayS of the settlement or
judgment, Report the amount of the personal injury settlement by completeing Form SI-5
and sending it to the RRB with your remittance. Amounts that are not paid within 30
days are subject to interest charges from the date of settlement or judgment.

If the employee has received, or is to receive, workers’ compensation, please furnish the
‘information about such compensation requested on Form SI-5. You are not to withhold and
pay to the RRB any of the workers’ compensation payments but the RRB needs to know about
then.

We estimate that Form SI-5 takes an exerepe of 5 minutes to complete, including the time
for reviewing the instructions, getting the needed data, and reviewing the completed

form. Federal agencies may not conduct or sponsor, and respondents are not required to
respond to, a collection of information unless it displays a valid OMB number. If you

wish, send comments regarding the accuracy of our_estimate or any other aspect of this

form, including suggestions for reducing the completion time to the Chief of Information
Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.

Railroad Retirement Board
SI-1B PROC. DATE REQ. CODE
0000