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

 

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Health Declaration Form

Have you experienced or are you currently experiencing any of the following:

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Health Declaration Form Page 2

Have you experienced or are you currently experiencing any of the following:

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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 upload a copy of your current medical certificate. You can upload a PDF, jpg or other image file. You can even take a photo with your smartphone and save it to your computer. Please click the "Choose File" button below.