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 656KB)

ACC249 Request for reimbursement of Pharmaceutical Costs (DOC 194KB)

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

Fact sheets

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

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

ACC583 Help for injuries (PDF 415KB)

ACC2399 Getting help after an injury (PDF 591KB)

INOIS01 Requesting official information (DOC 140KB)

INPIS01 Collecting and sharing your information (DOC 135KB)

INPIS02 Requesting personal information (DOC 135KB)

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

Information booklet

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

Death from injury

Forms

ACC136 Funeral grant payment authority (DOC 161KB)

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

Treatment injury

Forms

ACC2152 Treatment injury claim (DOC 123KB)

Fact sheets

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

Managing at home and work

Fact sheets

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

FSREB02 Supporting your independence – Equipment (DOC 67KB)

Transport

Forms

ACC250 Request for transport costs (PDF 40KB)

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

Fact sheets

FSENT02 Travel to treatment or rehabilitation (PDF 28KB)

Serious/long-term injuries and permanent impairment

Forms

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

ACC554 Medical Certificate (DOC 172KB)

Fact sheets

LSIAIS01 All about lump sum payments & independence allowances (PDF 39KB)

LSIAIS02 All about the independence allowance – single payment offer (PDF 25KB)

LSIAIS03 Impairment assessment reports for full self cover Accredited Employers (PDF 19KB)

SIIS01 Personal and property orders (PDF 262KB)

Weekly compensation

Fact sheets

FSWC01 Weekly compensation – general information (PDF 34KB)

FSWC02 Weekly compensation – employee (PDF 30KB)

FSCW03 Weekly compensation – self-employed (PDF 33KB)

FSWC04 Weekly compensation – shareholder employee (PDF 37KB)

FSWC05 Earning while on weekly compensation (PDF 40KB)

FSWC06 Interim weekly compensation (PDF 23KB)

Complaints, reviews and appeals

Forms

ACC33 Review application (DOC 182KB)

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

ACC709 Complaint form (DOC 178KB)

Fact sheets

ACC255 Working together (PDF 131KB)

ACC2393 Working together to resolve issues (PDF 772KB)

REVIS01 All about review hearings (PDF 92KB)

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 497KB)

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 29KB)

Fact sheets

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

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

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

Reviewed: 19 October 2015