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RRB Form SI-10: Statement of Authority to Act

Railroad employees too ill to manage their own sickness benefit claims need someone to sign for them, and this form gives that person authority. A relative or other individual explains why the employee can't act, and the employee's health care provider confirms it. The signer can then sign claim forms on the employee's behalf under the Railroad Unemployment Insurance Act.

Who completes it

The person acting for the employee completes Section 1, describing the employee's condition and their relationship. The employee's health care provider completes Section 2, certifying after examination that the employee can't sign forms or transact claim business, with name, signature, office address and National Provider Identifier.

Submitting and payment

How to submit it
The acting person returns it to the RRB with the next application or claim form they file. It is page 3 of the combined SI-1a, SI-10 and SI-1b packet on rrb.gov.
Who pays
No fee is provided; the companion SI-1b states the RRB is not liable for any charge for completing that form.

Good to know

  • Not needed when the employee can sign papers, or sign by mark, and understands the transactions relating to his or her sickness benefits.
  • A non-relative must state the relationship and explain why no relative is acting, for example a union chairman for an employee with no immediate family.
  • The acting person signs claims with their own full name and writes On behalf of and the employee's full name beneath it.
  • The acting person must promptly notify the RRB when the employee's condition changes and they no longer need to act.

Get the official form

Download the current version from the source each time; forms change without notice.

Statement of Authority to Act for Employee

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When does a health care provider need to complete RRB Form SI-10?

Only when a sick or injured railroad employee is unable to sign the sickness benefit forms. The SI-1b Statement of Sickness asks providers to complete Section 2 of the SI-10 if the patient is incapable of signing. If the employee can sign, even by mark, the form isn't needed.

What does the provider certify on Form SI-10?

In Section 2 you state that you have examined the employee and found them incapable of signing forms and transacting business relating to their sickness benefit claims under the Railroad Unemployment Insurance Act. You print your name, sign, date it, and add your office address and National Provider Identifier.