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Stanmore Bay, Whangaparaoa
09 444 1434

ACC Claim Form

If your injury is as a result of an accident you may be entitled to support with your rehabilitation fees from ACC. If this could be the case please complete this ACC claim form as well as the Registration Form.

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We have received your submission.

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Employment type
Work intensity
Did the accident occur at work?
Is this injury the result of a motor vehicle accident?
Is this injury a result of a sports accident?
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, specialist, New Zealand Police and Treatment providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the accident.
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