Sun Life uses this 4-page certification when it administers FMLA leave for an employee's own serious health condition. The patient signs on page 1, then the provider marks which condition type applies (inpatient care, chronic, pregnancy and others), estimates continuous, intermittent or reduced-schedule leave, and names at least one job function the employee cannot perform. Sun Life reviews it to decide the leave request.
The employee signs as the patient in Part A before handing the form over. The health care provider completes Section 1 (contact details and Parts A, B and C) and signs the certification on page 3.
The opening instructions tell the employee to complete and sign their part before giving the form to the provider. The provider section starts with your name, business address, type of practice or medical specialty, phone, fax and email. The form asks you to provide this contact information, complete all relevant parts of the section and sign at the end. Section 1 runs from page 1 to page 3 and contains Parts A, B and C.
Page 1 holds the patient's name, date of birth and signature, followed by the approximate date the condition started or will start and its probable duration. A notice above these fields says not to provide genetic test results, genetic services or the manifestation of disease in family members, and that some state or local laws may not allow disclosure of the diagnosis or course of treatment.
Check each category that fits: Inpatient Care with admission and discharge dates and any incapacity beyond the stay; Incapacity Plus Treatment with dates of incapacity, visit dates and prescription medication; Pregnancy with expected delivery date; Chronic Conditions needing treatment visits at least twice a year; Permanent or Long-Term Conditions under continuing supervision; and Conditions Requiring Multiple Treatments. Then briefly describe other relevant medical facts about the condition.
Estimate additional leave not already captured in Part A. For a continuous period of incapacity, including treatment and recovery, give the estimated start and end dates. Page 3 continues with intermittent leave: start and end dates of the intermittent period, then separate frequency and duration estimates for flare-ups and for treatment.
If a reduced schedule is medically necessary, give start and end dates, hours per day and days per week. Two more items cover planned medical treatments with their dates, such as prenatal appointments, and referrals to other health care providers, where you state the nature of the treatment, such as physical therapy. Mark only the patterns that apply to this patient.
Confirm that the employee was, is or will be unable to perform one or more job functions because of the health condition, and identify at least one function. This is the only place on the form that ties the medical facts to the employee's job, and it sits directly above the provider certification on page 3.
Sign and date the statement certifying that the information is true and complete and that you have read, or had read to you, the fraud warning for your state. The date uses the mm/dd/yyyy format. Page 4 lists Sun Life's mail, fax and email channels for returning the form.
Download the current version from the source each time; forms change without notice.
Family and Medical Leave Act (FMLA) – Own Serious Health Condition Certification
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.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Two people sign. The patient signs in Part A on page 1 before the form goes to the provider. The health care provider signs and dates the certification on page 3, confirming the statements are true and complete and that they have read, or had read to them, the fraud warning for their state.
GAMSFM-11127 certifies FMLA leave for the employee's own serious health condition. Sun Life lists GAMSFM-11129 separately as the FMLA Own Serious Health Condition with Disability Claim form, used when the leave is filed together with a disability claim. Complete whichever version the employee or Sun Life sent for the claim.
Part B asks for two separate estimates, one for flare-ups and one for treatment. For each, give how often episodes happen (per day, week, month or year) and how long each lasts (hours, days, weeks or months), plus the start and end dates of the intermittent period. The form's example is 2 hours each episode, 1 time per week.
Part C, Essential Job Functions, asks you to confirm that the employee was, is or will be unable to perform one or more job functions because of the health condition, and to identify at least one of those functions. It sits just above the provider certification and signature on page 3.