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.

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Page last updated: 10 April 2019