Forms and fact sheets

This section contains ACC claims forms and fact sheets for you to print. You can complete the forms and post or fax it 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 194K)

ACC6300 Authority to collect medical and other records (DOC 166K)

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 Getting help after an injury (PDF 591K)

INOIS01 Requesting official information (DOC 140K)

INPIS01 Collecting and sharing your information (DOC 135K)

INPIS02 Requesting personal information (DOC 135K)

HCSIS01 Tax and payment information for clients and carers (DOC 126K)

Information booklet

ACC7023 Deciding who’ll provide your paid care and support (PDF 295K)

Death from injury

Forms

ACC136 Funeral grant payment authority (DOC 161K)

ACC21 Advice of accidental death (includes fact sheet Lodging an accidental death claim with ACC) (PDF 267K)

Treatment injury

Forms

ACC2152 Treatment injury claim (DOC 123K)

Fact sheets

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

Managing at home and work

Fact sheets

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)

SIIS01 Personal and property orders (PDF 262K)

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 Review application (DOC 194K)

ACC34 Request to withdraw a review application (DOC 166K)

ACC709 Complaint form (DOC 178K)

Fact sheets

ACC255 Working together (PDF 131K)

ACC2393 Working together to resolve issues (PDF 772K)

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 information sheet below as it now includes information on the Code of ACC Claimants’ Rights.

ACC2393 Working together to resolve issues (PDF 497K)

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)

Updated: 26 May 2016

Reviewed: 19 October 2015