VLF Loss of Licence Health Questionnaire | VIPA | The Association for Virgin Australia Group Pilots
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VLF Loss of Licence Health Questionnaire

Home » VLF Loss of Licence Health Questionnaire

Please read all information regarding VLF and complete all sections. Each section in this form is relevant to our consideration of your application for membership.

Membership of VIPA Loss of Licence Fund Limited ACN 163 594 269 (VLF) is available to ‘eligible members’, namely commercial pilots employed by the Virgin Australia Group, who are current, financial VIPA members, under the age of 65 years at the commencement of the Protection Year, and other commercial pilots approved as Associate members of VIPA. All pilots joining VLF are required to complete this health questionnaire.

Once you click Submit, your details will be forwarded to VFS to be assessed as part of your VLF application.

It is important for all applicants and members to truthfully, accurately and fully answer the questions in this questionnaire, as failure to do so may result in removal or expulsion from membership of VLF, or a decision by VLF not to offer protection, or not to pay a claim made by the member.
 

How we protect your privacy

We are committed to protecting your privacy. We use the information you provide to assist with handling membership applications and claims for protection. The information we collect on any application forms, including your personal details will be given to KJ Risk Group Pty Ltd (KJRG) and VLF so they can decide whether to accept your application for membership and protection. Personal information is also shared between KJRG and VLF, when you make a claim for protection. If you decide not to give us personal information we may not be able to process your membership application or your claim for protection. Your personal information may be used to offer other products and services. If you do not wish to receive those offers, you can unsubscribe by contacting VIPA Financial Services.

For more information about how you can access the personal information we hold and seek correction of it or make a complaint, please review our Privacy Policy. You can ask us for a copy or visit our website vipa.asn.au

How can you contact us?

If you have any questions about this Health Questionnaire, we can be contacted at:
VIPA Financial Services Pty Ltd
ACN: 168 177 893
AR No. 455 638
Suite 203, 1 York Street
Sydney NSW 2000
Ph: 1800 116 460, option 5
Em: vfs@vipa.asn.au

 

Applicant Details

Given Name*

Last Name*

Male Female 

Company*

If Other, please state:

Rank*

Fleet*

Base*

Salary (excl. Superannuation)*

Employee Number*

Date of Birth*

Mobile Phone*


Health Declaration

Please answer every question


1. What is your current height (cm)?

2. What is your current weight (kg)?

3. In the past 12 months, have you smoked tobacco or any other substance?
 Yes No

If Yes, please provide an explanation as to the substance smoked and the volume per day.

4. Have you ever had cancer or tumours of any type?
 Yes No

If Yes, please provide details including when this occurred.

5. Are you aware of any medical condition or issue that may require you to undergo surgery in the future?
 Yes No

If Yes, please provide details.

6. Have you ever suffered from high blood pressure, cholesterol, stroke or paralysis of any description?
 Yes No

If Yes, please provide details including when this occurred.

7. Have you ever had any cardiovascular complaint?
 Yes No

If Yes, please provide details including when this occurred.

8. Have you ever suffered from diabetes, kidney or bladder problems?
 Yes No

If Yes, please provide details including when this occurred.

9. Do you drink alcohol?
 Yes No

If Yes, how many drinks per week do you drink on average?

10. Have you ever been diagnosed with or received treatment for any mental health condition?
 Yes No

If Yes, please provide details including when this occurred.

11. Do you now have or have you ever had any disease of, or injury to, the neck or spine including back strain, disc disorder, sciatica or other non-specific back pain?
 Yes No

If Yes, please provide details including when this occurred.

12. During the last 5 years, have you taken or are you taking prescribed medication of any kind?
 Yes No

If Yes, please provide details.

13. Have you ever had more than 15 days absent from work in a 12 month period due to injury or illness?
 Yes No

If Yes, please provide details including when this occurred and the circumstances.

14. Are you currently covered by a Loss of Licence or Income Protection Policy?
 Yes No

If Yes, please provide details.

15. Have you ever claimed under any Loss of Licence or Income Protection cover?
 Yes No

If Yes, please provide details.

16. Have you ever been refused cover by a Loss of Licence insurer or Discretionary Mutual Fund (DMF)?
 Yes No

If Yes, please provide details.

17. In addition to the responses provided above, do you have any other pre-existing health conditions (injuries or illnesses)?
 Yes No

If Yes, please provide details.


Declaration and Signature

I, the Applicant, declare that I am not aware of any past or present injury or illness that may give rise to a claim for Loss of Licence benefits that has not been disclosed above, and that the above information I have disclosed is true, accurate, full and complete. I understand that if I have misrepresented or not properly disclosed any information which is requested in this form, it may affect my entitlement to hold membership of VLF, to seek protection from VLF and/or claim for Loss of Licence benefits.


Your Full Name as Signature*

Date*

By clicking Submit you indicate you have accepted the Terms and Conditions as above.

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