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Puerto Rico SINOT Form SI-1: Disability Claim (Part C)

Puerto Rico workers apply for SINOT temporary non-occupational disability benefits on Form SI-1 when an illness or injury unrelated to work or a car accident keeps them from working. Part C, the medical or psychological certificate, is where each treating provider records the diagnosis, treatment period and period of disability. The Department of Labor's SINOT program decides benefits from the full application.

Who completes it

The worker completes Part A and each employer completes Part B; each treating physician, chiropractor or psychologist, or the treating institution's medical records custodian, completes a separate Part C.

Submitting and payment

How to submit it
The worker mails the full application to the DTRH Bureau of Workers' Benefits SINOT program or delivers it at a DTRH office within three months of the start of the disability; there is no online filing.
Who pays
The SI-1 sets no fee and names no payer for completing Part C.

Good to know

  • Part C asks whether the disability relates to work or a car accident; SINOT pays only for non-occupational conditions not caused by traffic accidents.
  • Use diagnosis codes, note any pregnancy complications, and give the treatment period, the disability period and any hospitalization of 24 hours or more.
  • Part C also documents dismemberment or total and permanent loss of vision, with its date, cause and extent; that benefit must be claimed within six months.
  • The current form is the Spanish SI-1 (amended 2025). Workers insured through a private SINOT plan or a self-insured employer use that plan's form instead.

Get the official form

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

Application for Disability Benefits Covered by Act 139 (Industrial and Agricultural Phase) - Part C Medical or Psychological Certificate

Solicitud de Beneficios por Incapacidad, Ley Núm. 139 del 26 de junio de 1968, enmendada (Fase Industrial y Agrícola) - Parte C Certificado Médico o Psicológico

Official pagePDFVersión en español

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

Who can complete Part C of Puerto Rico's SI-1?

A physician, chiropractor or psychologist treating the worker who is authorized to practice in Puerto Rico or where they reside. The medical records custodian of the treating institution may also complete it. If the worker sees several providers, each one completes a separate Part C.

Is the SI-1 available in English?

The current form is the Spanish SI-1, amended in 2025. An English version titled DI-1 exists, but it is an older June 2015 scanned edition that cannot be filled in electronically, so the Spanish Part C, Certificado Médico o Psicológico, is the current version.

What is the deadline for a SINOT disability claim?

The law requires the application within three months after the disability begins, and a worker who files later must explain the delay in Part A. For dismemberment or loss of vision, the separate benefit must be requested no later than six months after it occurs.