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