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

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

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. Download this form and complete it on your device, or print it and complete it by hand.

Page last updated: 10 April 2019