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Unum CL-1263-MA Massachusetts PFML Certification

When a Massachusetts employer's paid family and medical leave coverage is a private plan insured by Unum, the serious health condition behind a claim is certified on this eight-page packet. It covers the employee's own condition or a family member's condition that needs the employee's care. The provider's pages ask about onset, duration, job or military relation, the serious health condition category and the leave needed.

Who completes it

The employee and employer complete pages 1 to 5 and the top of page 6. The health care provider of the employee or family member answers questions 1 to 8 on pages 6 and 7 and signs with printed name, practice type, phone and fax.

Submitting and payment

How to submit it
The completed packet goes to Unum's Benefits Center by fax or by mail, using the details printed on each page.

Good to know

  • Unlike Unum's other state versions, question 4 asks whether the condition is related to the patient's military service; question 3 asks whether it is a job-related injury.
  • Question 7 asks you to check the serious health condition category: hospital care, absence plus treatment, pregnancy, chronic conditions, permanent or long-term conditions, or multiple treatments.
  • Incapacity on this form follows M.G.L. c. 151A, section 25(c): inability to perform the functions of one's position, or for a former employee, the most recent position or other suitable employment.
  • Use CL-1263-MA only for a Unum-insured private Massachusetts plan. Newborn bonding uses CL-1297-MA, and the authorization is CL-1088-PFL. Revision 05/26 is current.

Get the official form

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

Massachusetts PFML Certification of Health Care Provider

Official pagePDF

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

When does a Massachusetts provider get Unum's CL-1263-MA?

When the patient's employer meets Massachusetts paid family and medical leave obligations through an approved private plan insured by Unum. The claim is then administered by Unum, so the provider completes Unum's certification pages, not the Department of Family and Medical Leave's own form.

How specific do the leave estimates on CL-1263-MA need to be?

The provider instructions ask for your best estimate based on examination and experience, and warn that terms like lifetime, unknown or indeterminate may not be enough to determine coverage. Question 8 asks for continuous dates, visit frequency, recurring episodes or a reduced schedule in hours per day and days per week.

Which Unum form is used for bonding with a newborn in Massachusetts?

Bonding leave uses CL-1297-MA, a one-page documentation of birth completed by the health care provider, and Unum also accepts other official proof of birth. A full serious health condition certification on CL-1263-MA is not needed just to bond with a new child.