Download and complete the Medical indemnity request to aggregate payments for the same claim form.
This is in accordance with Section 31 (High Cost Claim Indemnity Scheme), Section 34ZE (Run-off Cover Indemnity Scheme) or Section 34ZZC (Allied Health High Cost Claim Indemnity Scheme) of the Medical Indemnity Act 2002.
An authorised representative of the MII must complete and sign this form and provide it to the MDO. The MDO must provide this supporting document when submitting an application through MIOC for aggregated payments.
To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.
If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.