A railroad employee applying for sickness benefits under the Railroad Unemployment Insurance Act needs medical evidence on this one-page statement, the last page of the SI-1a application packet. It records when the patient became sick, examination dates, diagnosis and concurrent conditions, any surgery or hospital stay, maternity dates and the date the patient should be able to resume work.
A provider trained in medical, surgical, dental or psychological diagnosis, a certified nurse-midwife for pregnancy or childbirth, a hospital supervisory official, a chiropractor, a certified PA or a nurse practitioner completes all of SI-1b. The employee completes the SI-1a application.
Download the current version from the source each time; forms change without notice.
Statement of Sickness
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.
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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The form lists six groups: a provider trained in medical, surgical, dental or psychological diagnosis of the condition; a certified nurse-midwife for pregnancy or childbirth; a supervisory official of a hospital or similar institution; a chiropractor; a Physician Assistant-Certified; or a nurse practitioner.
The instructions say to complete it and return it to the patient immediately for prompt mailing, because delays can cost benefits. The patient mails it with the SI-1a application to the RRB's RUIA unit in Houston. You may send supplementary medical information directly to the RRB.
No Spanish version of the SI-1b is published. The RRB does publish a Spanish sickness benefits guide, UB-11S, for employees. The provider statement itself is a flat, non-fillable English PDF.