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.
This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.
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: 26 March 2020
This information was printed 11 January 2021 from https://www.servicesaustralia.gov.au/organisations/health-professionals/forms/mo042. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/individuals/site-notices when using this material.