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.

Full Name

Date of injury

Approximate time of injury, AM or PM

Place of injury e.g. sports field, home

Location of injury e.g. Auckland, Christchurch

Describe how the injury happened

Occupation

Employment type

Name and Address of the business you are employed by/own

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?

Type of Sport? if applicable

Do you agree to the following ACC declaration? YES or NO

I DECLARE - The information I have given about this claim is true and correct and that I have not withheld any information

Do you agree to the following authorisation? YES or NO

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.

ACC Claim Form

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ACC Claim Form

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