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ACC Registration

Title

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Name

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Phone (Mobile Preferred)

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Ethnicity

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Is this an ACC injury

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Yes

No

Date of Injury

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Location (City or Town)

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Place of Injury (eg Home, School, Road)

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How did the injury happen (Specific incident required. Please include the body part injured)

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Did the injury occur at work?

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Yes

No

If yes, please specify the Business / Employers name and address

Address

Is this injury as a result of a motor vehicle accident?

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Yes

No

Is this injury as a result of a sports accident?

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Yes

No

If yes, what sport?

ACC DECLARATION - I DECLARE – The information I have given about this claim is true and correct and that I have not withheld any information.
I AUTHORISE – The treatment provider to lodge the claim for me. The collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation, rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention I should receive. ACC to contact anyone who holds relevant information, including any external agencies or service providers (such as medical practitioners, specialists, New Zealand Police and Treatment Providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the accident.

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Yes

If under 16, must be signed by parent/guardian. Please state the parent/guardians full name.

E-Signature

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Yes, I declare the information I have given about this claim is true and correct and that I have not withheld any information

Sign here

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