Form 16874 2026

1. Click ‘Get Form’ to open Form 16874 in the editor.
2. Begin by filling out Section 1, which requires your employer's information. Enter the name and contact details of Union Pacific Railroad.
3. Complete the employee section by providing your name, job title, phone number, service unit or department, and employee ID.
4. Indicate the reason for your leave by checking the appropriate box and providing any necessary details such as estimated due dates or care requirements.
5. In the health care provider section, ensure that all applicable questions are answered thoroughly. This includes medical facts supporting your condition and any required follow-up visits.
6. Review all entries for accuracy before signing and dating the form. Ensure that both you and your family member (if applicable) have signed where indicated.
7. Finally, return the completed form to Union Pacific Railroad’s Health and Medical Department via mail or fax as specified at the bottom of the form.

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