It's easy to start the process. simply fill in this form and submit. or if you prefer a call first, get in touch.

Your Details

Name *

Name

Name of person to be covered

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Email Address *

Your ACC No. *

Check last year's ACC invoice or ask your accountant

Your IRD No.

Your Address *

Your Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your best phone contact

(###)

###

####

Your Accountant's Name *

Your Accountant's Name

First Name

Last Name

Your Accountant's Phone Number

(###)

###

####

My Tax agent should be the primary contact

Business Details

Your Trading/Company Name

Date of business establishment

YYYY

Type of Business

Please use the ACC description. Ask your accountant or check your ACC Invoice

Classification Number

Has your Classification Number changed from last year

How Many hours per week do you work?

Please provide an accurate estimate of your hours worked

Self-employed details

Complete only if you are self-employed. Shareholder-employees should use the next section.

Structure of your business: *

Sole Trader

Partnership

No. of partners in your business *

No. of full-time equivalent employess (FTEs) *

Your share of the business *

Self employed earnings for the past three years

Year End 31/03/14 *

Year End 31/03/15 *

Year End 31/03/16

Shareholder-employee details

Complete this only if you are a shareholder-employee and don't have PAYE deducted from your salary

Structure of your business *

Sole Trader

Shareholder-employees

Company IRD Number *

Your share of income from this business *

Company ACC Number *

Your Self-employed earnings liable for ACC payments for the past three years

Year End 31/03/14

Year End 31/03/15

Year End 31/03/16

Business Partner's details

Is your partner applying for AA CoverPlus Extra *

Partner's ACC number *

Check last year's statement

Partner's IRD Number *

Is your partner a 'passive earner' *

A passive is a person who has no physical or mental input into the running of the business, therefore their earnings are not lianle for ACC. Ask your accountant or Inland Revenue if you are unsure.

Cover details

Choose the option you require *

ACC CoverPlus Extra

ACC CoverPlue Extra with lower levels of weekly compensation

Annual ACC CoverPlus Extra cover you're applying for:

Please note maximums and minimums apply

If you're applying for cover that is significantly more or less than you earned last year, please tell us why: *

By Submitting this form you understand that:

The information ACC collects on this form will be used in accordance with the Privacy Act 1993 to process this application for an ACC CoverPlus Extra policy. In collecting, using and storing this information, ACC will at all times comply with the guidelines of that Act. This authority relates to all aspects of my policy and authorises ACC to contact anyone who holds relevant information, including any external agencies or service providers. I have the right to see and ask for correction of any information that ACC holds about me. I authorise: The collection and release of any information about me to the extent that it is needed to determine cover and/or assess my entitlement to compensation. I declare that: The information supplied on this form is true and correct and that I have not withheld any information likely to affect my application. I will inform ACC of any change in circumstances that may affect my entitlements. I have read and understood the Privacy Act 1993 information at left.