Statutory declaration - Midwife Professional Indemnity Scheme - Online claim form (MO042)

Use this form to support a Midwife Professional Indemnity Scheme (MPIS) online claim application.

Download and complete the Statutory declaration - Midwife Professional Indemnity Scheme - Online claim form.

A person authorised to represent your organisation must complete and sign this form.

If the statutory declaration is not provided with each new online claim application a Commonwealth Contribution Indemnity Scheme payment cannot be made.

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.

Page last updated: 23 September 2022