Forms and fact sheets

This section contains ACC claims forms and fact sheets for you to print. Forms may be completed and posted or faxed to us.

Downloading and requesting forms

Most of these documents are in PDF format. For more help about accessing PDFs, please go to Downloading software.

If you want forms and fact sheets to be posted out to you go to ACC publications.

General claims information

Forms

ACC001 Request for assistance (PDF 656K)

ACC249 Request for reimbursement of Pharmaceutical Costs (DOC 142K)

ACC167 Authority for the collection and disclosure of information (DOC 133K)

Fact sheets

ACC592 Getting help if you’re injured visiting our country (PDF 1.4M)

ACC593 Getting help with an injury if you’ve been travelling overseas (PDF 1.5M)

ACC583 Help for injuries (PDF 415K)

ACC2399 How you can get help after an injury (PDF 940K)

INOIS01 Requesting Official Information (DOC 100K)

INPIS01 Collection and Disclosure of Information (DOC 100K)

INPIS02 Requesting Personal Information (DOC 100K)

Death from injury

Forms

ACC136 Funeral grant payment authority (DOC 81K)

ACC21 Advice of accidental death (includes fact sheet Lodging an accidental death claim with ACC) (DOC 214K)

Treatment injury

Forms

ACC2152 Treatment injury claim (DOC 123K)

Fact sheets

ACC589 Getting help with an injury caused by treatment (PDF 85K)

Dental injury

Fact sheets

ACC591 Getting help for dental Injuries (PDF 740K)

Hearing loss

Fact sheets

HLSIS04 Assessing cover for hearing loss (DOC 98KB)

HLSIS05 Helping with your hearing loss (DOC 92KB)

HLSIS06 Assistance from other agencies (DOC 86KB)

Sexual abuse or assault

Fact sheets

SCUIS01 How we can help with a mental injury resulting from sexual assault or abuse (DOC 190K)

SCUIS02 All about support sessions after sexual abuse or sexual assault (DOC 229K)

Managing at home and work

Fact sheets

FSREB05 Help at home while you recover (PDF 876K)

FSREB12 Artificial Limbs – Supporting your independence (DOC 36K)

FSREB02 Supporting your independence - Equipment (DOC 67K)

Transport

Forms

ACC250 Request for transport costs (PDF 40K)

ACC253 Request for prior approval: Transport and accommodation assistance (PDF 37K)

Fact sheets

FSENT02 Travel to treatment or rehabilitation (PDF 28K)

Serious/long-term injuries and permanent impairment

Forms

ACC54 Application for Lump sum/independence allowance (DOC 125K)

ACC554 Medical Certificate (DOC 172KB)

Fact sheets

LSIAIS01 All About Lump Sum Payments & Independence Allowances (PDF 39K)

LSIAIS02 All About the Independence Allowance - Single Payment Offer (PDF 25K)

LSIAIS03 Impairment Assessment Reports for Full Self Cover Accredited Employers (PDF 19K)

Weekly compensation

Fact sheets

FSWC01 Weekly compensation - general information (PDF 34K)

FSWC02 Weekly compensation - employee (PDF 30K)

FSCW03 Weekly compensation - self-employed (PDF 33K)

FSWC04 Weekly compensation – shareholder employee (PDF 37K)

FSWC05 Earning while on weekly compensation (PDF 40K)

FSWC06 Interim weekly compensation (PDF 23K)

Complaints, reviews and appeals

Forms

ACC33 Application for Review (DOC 102K)

ACC034 Request to withdraw a review application (DOC 78K)

ACC709 Complaint form (DOC 101K)

Fact sheets

ACC255 Working Together (PDF 498K)

ACC2393 Working together to resolve issues (PDF 363K)

REVIS01 All about review hearings (PDF 92K)

Code of ACC Claimants’ Rights fact sheets

Note:
The An Introduction to the Code of ACC Claimants’ Rights fact sheets have been discontinued. Please refer to the Working together to resolve issues fact sheets below as they now include information on the Code of ACC Claimants’ Rights.

ACC2393 Working together to resolve issues (PDF 363K)

ACC5320 Working together to resolve issues (Cook Islands Maori) (PDF 724K)

ACC5321 Working together to resolve issues (Samoan) (PDF 3.1M)

ACC5322 Working together to resolve issues (Tongan) (PDF 661K)

ACC5323 Working together to resolve issues (Maori) (PDF 1.1M)

ACC5324 Working together to resolve issues (Hindi) (PDF 798K)

ACC5325 Working together to resolve issues (Chinese) (PDF 960K)

ACC5326 Working together to resolve issues (Korean) (PDF 1.0M)

Cultural Access fact sheets

Te tauturu te ka rauka mai me mate ake tetai tangata no te pakia (injury) tei tupu ki tona kopapa

Te tauturu te ka rauka me kua tupu te kino ki toou kopapa i te tuatau i atoro mai ei koe i to matou basileia

Te tauturu te ka rauka mai me tupu te pakia ki toou kopapa ia koe e tere aere ra na te au basileia i vao mai

Anga ha’o ma’u ha tokoni hili ha’o lavea

Ko hano ma’u atu ha tokoni hili ha malolo ’a ha taha mei´ ha lavea

Ko hano ma’u atu ha tokoni kapau ’oku´ ke lavea lolotonga ha’o ’eve’eva mai ki homau fonua´

Ko hano ma’u atu ha tokoni ’i ha'o lavea lolotonga ha’o folau atu ki tu’apule’anga

상해를 입은 분들을 위한 지원 제도

상해 사망자의 유가족을 위한 지원 제도

뉴질랜드 방문 도중 상해를 입은 분들을 위한 지원 제도

해외 여행 중 상해를 입은 분들을 위한 지원 제도

意外受傷後如何尋求幫助

意外傷亡後如何申請幫助

海外訪客來新西蘭旅行時意外受傷如何獲得幫助

在海外旅遊時意外受傷怎樣得到幫助

Employers and Agents

Forms

Return to work plan template - basic (DOC 29K)

Fact sheets

ACC1695 Helping employees get back to work: Step by step overview (PDF 55K)

ACC1699 Helping employees get back to work: Common questions (PDF 53K)

ACC1701 Helping employees get back to work: Workplace assessments (PDF 50K)

Last updated: 19 March 2014