Apply for Cover

It is essential that you are honest and truthful and thorough when you complete the following Health Declaration Form.

This is to avoid a possible future claim being declined.

Note the declaration and warrantees at the end of the form - these are very important

NOTE: This form will not update your current address.

If you have changed address please login and follow the instructions.

If you are already a member your login is your email address held by the MBF

Apply for Cover Page 1

First Name

Middle Name(s)

Surname

Given Name Initials

Postal Address 1

Postal Address 2

City

Post Code

Home Phone Number

Home Fax Number

Mobile Phone Number

Email Address

Date of Birth

Application Date

2022-05-18

Apply for Cover Page 2

Current Employer Commencement Date

Gross Salary

Total Cover Available

Amount of Cover Requested

Rank

Licence Number

ALPA Membership Number

ALPA Joining Date

Previous Emplyment History

Previous Employer Cover Allowance?

No Yes

Previous Employer Cover Details

Apply for Cover Page 5

NOTE: If you are unable to submit the form please ensure all information on each page is filled out. You can step back through the form with the PREV button.

Hereby declare and warrant 1. That the answers given above are in every respect true, correct and complete. 2. That I have not sustained any bodily injury or suffered from any illness which may result in the permanent or temporary loss or cancellation of my licence, medical validity certificate or other document that I am required to hold to enable me to exercise the privileges of my New Zealand Civil Aviation/CASA Certificate. 3. That I am not at the present time afflicted by any sickness disease, deafness or deterioration in health and that I have not withheld any information regarding my health and medical history. Any Medical Adviser to the New Zealand Air Line Pilots' Mutual Benefit Fund is authorised to see this application and to obtain such information as he/she shall require from the Principal Medical Officer of any Civil Aviation Licencing Authority or any medical practitioner I have consulted regarding my health. I acknowledge and authorise that the information given in my application for membership or obtained pursuant to the above authority can be disclosed to such parties as the Trustees of the Fund or their medical adviser considers necessary to assess my entitlement to any benefit or right to continued membership of the Fund. Any information obtained pursuant to this authority will be held at the office of the Mutual Benefit Fund and I understand that I have the right of access to and correction of any information held about me.

Please email a copy of the front and back of your medical certificate to the MBF Office. The email address is office@pilotsmbf.org.nz

I have read and accept the conditions above. Before this application is accepted I will sign the page that is emailed to me.

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