Complete all items by typing or printing neatly in ink. Do not skip any items unless directed to do so. If you need more space to answer a question, enclose a separate sheet of paper. Be sure to sign your name and date the form before mailing. Have your doctor complete Form SI-1b, Statement of Sickness. Do not separate the Forms SI-1a and SI-1b.
Read the following instructions carefully before completing your SI-1a application. If your application is not completed correctly, your benefits may be delayed. Contact your local RRB office if you have questions or need assistance in completing the form. If you are completing the application for the employee, refer to the instructions on completing Form SI-10, Statement of Authority to Act for Employee.