Applicant Details

Eligibility Criteria*

 Financial Member of VIPA or have applied for Membership

 Commercial pilot with Virgin Australia Group or an Associate VIPA member

 Under the age of 65 years as at 1 May 2020

If you are unable to check any of the above boxes, please do not continue with the application, and contact VFS on 1800 116 460, option 5 to discuss your options.

Given Name*

Last Name*

Male Female 

Company*
- Select -Virgin AustraliaVARAOther

If Other, please state:

Rank*
- Select -CaptainFirst OfficerSecond Officer

Fleet*
- Select -B737B777A330A320ATR72F100

Base*
- Select -BNEMELPERSYDCBR

Salary (excl. Superannuation)*

Employee Number*

Date of Birth*

Mobile Phone*

Email*

Postal Address*

Suburb*

State
- Select -ACTNSWNTQLDSATASVICWA

Postcode*

Country

2020-2021 VLF Member Loss of Licence Protection Benefits Nomination

Nominate your maximum benefit amount by choosing your Group and benefit level

Group*

- Select -Narrow Body EAWide Body EAVARA EAVIPA Associate member

Narrow Body Pilots
EBA Amount: $3,004.77 provides maximum benefit of $700,000 or limit in your particular age band whichever is the lesser
- Select -Option 1: EA contribution gives $700,000 or limit

Wide Body Pilots
EBA Amount: $3,004.77 provides maximum benefit of $700,000 or limit in your particular age band whichever is the lesser
- Select -Option 1: EA contribution gives $700,000 or limit

VARA Pilots
EBA Amount: $2,005 provides maximum benefit of 66.73% x $700,000 OR 66.73% x limit in your particular age band whichever is the lesser
- Select -Option 1: EA contribution gives 66.73% x $700,000 or limitOption 2: Increase to maximum benefit of $700,000 or limit in your particular age band. Cost to pilot = $999.77

Associate member Pilots
Contribution amount of $3,004.77 provides maximum benefit of $700,000 or limit in your particular age band whichever is the lesser.
- Select -Option 1: maximum benefit of $700,000 or limit in your particular age band. Cost to pilot = $3,004.77

Declaration

I, the Applicant:

1. Hereby apply for membership of VIPA Loss of Licence Fund Limited, ACN 163 594 269 (VLF) and warrant that I am eligible for membership of VLF.

2. Accept that an offer of VLF Membership by VIPA Financial Services Pty Ltd (VFS) means that I agree to be bound by the terms and conditions of membership and the Protection as set out in the Constitution and the Product Disclosure Statement.

3. Declare that the information supplied to VFS and VLF is correct to the best of my knowledge and belief and that it is not deficient in any material respect and I consent to the information being used by VLF and VFS in accordance with their privacy policy which can be found at www.vipa.asn.au

4. Understand that all particulars and information provided to VFS and VLF in the course of applying for membership and Protection and the basis for the exercise of discretion to grant the Protection are deemed to form part of the terms of the Applicant's entry as a member of VLF.

5. Acknowledge that I will assess the Constitution of VLF on VIPA's website at www.vipa.asn.au and I have received and read the Product Disclosure Statement for the Protection.

6. Agree to notify VFS if my eligibility status or contact details change from that provided at the time of my application, for example if I cease employment as a pilot or change employer.

7. Agree to notify VFS of any matter that will materially alter the information provided on or with my application for membership of VLF.

8. Understand that I must keep my VIPA membership current and paid at all times, and that the cover provided by VLF may be voided by letting my VIPA membership become unfinancial or lapse.

Your Full Name as Signature*

Date*

By clicking Submit you indicate you have accepted the Terms and Conditions as above, and nominate the LoL Protection Limit as indicated.

After you submit your application, please complete and submit the VLF Health Questionnaire.