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

14. Are you applying for sickness benefits because you were injured at work or have a work-related illness?

15. Have you filed or do you expect to file a lawsuit or claim against any person or company for personal injury?

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.

C. Were you injured in an automobile accident? 

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)

Name

Address

City, State, ZIP Code

Insurance Company (other vehicle)

Name

Address

City, State, ZIP Code

United States of America

Railroad Retirement Board

Form Approved

OMB No. 3220-0039

Section A Identifying Information

Section B Infirmity and Employment Information

Section C Accident and Insurance Information

1. Employee’s Name (First, Middle Initial, and Last)

3. Employee’s Street Address, City, State and ZIP Code

(Including Apartment Number)

2. Social Security Number

4. Date of Birth

Month Day Year

5. Sex

❏

❏

Male

Female

6. Telephone Number (Include Area Code)

( )

7. Date You Became Sick or Injured

9. Last Railroad Employer (Name of Company)

11. Last Railroad Occupation

8. Date You Last Worked for a Railroad

10. Location of Last Railroad Employment (City/State)

12. Department

13.

❏ Yes ❏ No

Driver (other vehicle)

Name

Address

City, State, ZIP Code

Policy Information (other vehicle)

Policy Number

Claim Number

❏ Yes ❏ No - Go to Item 16

Application for Sickness Benefits

Continued on Reverse Side SI-1a (03-12)

❏ Yes - Complete Items A-D, below ❏ No - Go to Item 16

– –
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 

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.

❏ ❏ Regular Wages. . . . . . . . . . . .. . . . . ________________________________________________________________

❏ ❏ Vacation Pay . . . . . . . . . . . . . . . . . . ________________________________________________________________ 

❏ ❏ Holiday Pay . . . . . . . . . . . . . . . . . . ________________________________________________________________

❏ ❏ Military Reservist Pay . . . . . . . . . . ________________________________________________________________ 

❏ ❏ Wage Continuation Pay . . . . . . . . . ________________________________________________________________ 

❏ ❏ Earnings from Self-Employment . . ________________________________________________________________ 

❏ ❏ 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.

❏ ❏ Sickness or Unemployment Benefits Under Any Other Law 1. Beginning Date of Payment

❏ ❏ Social Security Benefits 2. Gross Amount of Payment $ __________________ ❏ ❏ Railroad Retirement or Disability Annuity 3. How often do you receive the payment? ❏ ❏ Military Retirement Pay ❏ Weekly ❏ Monthly ❏ Yearly

❏ ❏

❏ ❏ Worker’s Compensation ❏ Other: ________________________________ Retirement Payments Under Another Law 

C. OTHER PAYMENTS

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

❏ ❏ Settlement, Judgment or Damages for Personal Injury 1. Date of Payment

❏ ❏ Advances 2. Paid By: __________________________________ ❏ ❏ 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 ___________________________________

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

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: _______________________________________ __

❏ Checking ❏ Saving E. Telephone No. (Include Area Code) (_______)____________________________ 

22.

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

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) HAVE YOUR DOCTOR COMPLETE THE ATTACHED STATEMENT OF SICKNESS

Section D Claim for Sickness Benefits Information

Section E Direct Deposit Information

Section F Certification and Signature

❏ Yes - Go to Item 19 ❏ No - Go to Item 18
5. Does the patient's condition require surgery? Yes No – Go to Item 6

6. Does the patient's condition require hospitalization? 

Yes – Enter the period of hospital confinement: From To

United States of America

Railroad Retirement Board

Form Approved

OMB No. 3220-0039

Statement of Sickness

Instructions: This form is to be executed by (1) a doctor trained in medical, surgical, dental or psychological diagnosis of

the infirmity described, (2) a certified nurse/midwife in cases of pregnancy or childbirth, (3) a supervisory official of a

hospital or similar institution, (4) a chiropractor, (5) a Physician Assistant - Certified, or (6) a nurse practitioner. This form

should be completed and returned to the patient immediately for prompt mailing; otherwise he/she may lose benefits.

Supplementary medical information may be attached or furnished directly to the Railroad Retirement Board (RRB) at the

address shown below. If such information is furnished, please include the patient's social security number and name on the

report. Please complete section 2 on the reverse side if patient is incapable of signing forms.

1. Patient's Name (First, Middle, and Last)

3. Have you examined or treated the patient for his or her injury or illness? Yes No – Go to Item 9

2. Patient's Social Security Number

The RRB is not liable for any charge in connection with completing this form.

❏

❏

❏

❏

a. Date patient became sick or injured

c. Probable date of next examination

4. Diagnosis and concurrent conditions

❏

❏

b. List all dates of examination and treatment for this infirmity

a. Date on which surgery was or will be performed

7. If patient is not working because of maternity or childbirth, complete 7a and 7b.

a. Date patient became unable to work b. Estimated or actual date of delivery

9. I certify that the information I am giving is true, complete, and correct. I understand that criminal and civil penalties may be imposed

.....on me for false or fraudulent statements or for withholding information to cause or prevent payment of benefits by the RRB.

Please print or type:

8. Give the date you believe the patient became or will become able to resume work in his or her occupation. 

(If indefinite or unknown, please give an estimated date.)

b. Surgical procedure that was or will be performed

Name of Doctor

Address Office Telephone Number (Include Area Code)

( )

National Provider Identifier

Date

Signature of Doctor Degree/Title

PAPERWORK REDUCTION ACT NOTICE TO DOCTOR

Medical evidence is needed to support the payment of claims for sickness benefits under the Railroad Unemployment Insurance Act (RUIA). The RRB is

authorized to collect this information under section 12(i) of the RUIA. You are not required to furnish this information. If you do not, however, no benefits

can be paid to your patient. We estimate this form and the form on the back of this page take an average of 8 and 6 minutes to complete, respectively.

The estimates include the time for reviewing the instructions, getting the needed data, and reviewing the completed forms. 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 completion time, to the Chief of

Information Resources Management, Railroad Retirement Board, 844 N Rush Street, Chicago, Illinois, 60611-2092. Send completed forms to: 

U.S. RAILROAD RETIREMENT BOARD

OFFICE OF PROGRAMS—OPERATIONS

POST OFFICE BOX 10695

CHICAGO, ILLINOIS 60610-0695

Doctor: See Reverse Side FORM SI-1b (06-09)

▲

▲

▲

No 
Statement Of Authority To Act For Employee

United States of America

Railroad Retirement Board

Form approved

OMB No. 3220-0034

SI-10 (06-09)

Instructions:

Complete Section 1 and have the employee's medical doctor complete Section 2. 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 union representative might explain: “I am his union chairman. He has no immediate family.”

Complete this statement by following the instructions in the UB-11 booklet under “Instructions for

Completing Forms, Statement of Authority to Act for Employee (SI-10).” Signing this statement gives you the

authority to sign any claim forms on behalf of the employee. When signing claim forms use your full name,

and beneath your signature, write “On behalf of ” and the employee’s full name.

Return this form with the next application or claim form you file with the RRB.

1.

2.

3.

Section 1

Section 2

Statement of Individual Acting for Employee

Statement of Employee's Doctor

It is my belief that

whose address is

is at this time incapable of signing forms in connection with obtaining sickness benefits under the Railroad

Unemployment Insurance Act; of transacting the necessary business relative to his or her application and claims

for such benefits; and of applying the proceeds of any sickness benefit payments. 

I believe the employee to be incapable because

My relationship to the employee is

(Employee's Name)

(Employee's Address)

(Briefly describe employee's condition)

(Social Security Number)

I affirm that, in the transaction of business relating to the application and claims of this employee, including the use

of any benefit payments, I will act on behalf of and in the best interest of the employee. I will promptly notify the

RRB at such time as this employee's condition changes so that I need no longer act for him or her. I understand that

criminal and civil penalties may be imposed on me for providing false, incomplete, or fraudulent statements; using

the benefits received on something other than the claimant; or for withholding information to cause the payment of

benefits. I certify that, to the best of my knowledge, the information I have provided is true, complete, and correct.

Name (please print)

Street Address (please print)

Signature

City State ZIP Code Date

Phone Number

( )

Name of Doctor (please print)

Office Street Address (please print)

National Provider Identifier

Signature of Doctor

City State ZIP Code Date

I have examined the employee named above and find that he/she is incapable of signing forms and transacting

business relative to his/her claims for sickness benefits under the Railroad Unemployment Insurance Act.

Instructions

It is not necessary to complete this form for an employee who can sign papers or can

sign by mark and understands transactions relating to his or her sickness benefits.