ACC45 Claim - IntelliMed

NHI Number (if known)

First Name(s)

Family Name/Surname

Date of Birth:

Accident Date

at time

Did the accident occur in New Zealand?

Yes

Accident Scene

Accident Location

Did the accident happen at work?

Yes

Which part of your body is injured? e.g. left wrist What were you doing? e.g. cleaning the kitchen How was the injury caused? e.g. slipped on wet floor

Please select the body part that is injured.
Tap body part again to unselect.

If sporting injury, name sport:

Did the accident involve a moving motor vehicle on a public road, driveway or beach?

Are you employed in NZ?

Yes

Your occupation

Your employment type, i.e., you are

What type of work do you do?

Employer/Business Name

Employer Address

Suburb

City/Town

Country

Postcode:

Occupation:

Please sign below (clear signature)

I authorise (tick the left checkbox):
- ACC to collect medical and other records which are or may be relevant to my claim
- The treatment provider to lodge this claim for me

I declare (tick the left checkbox):
- That the information I have given in this form is true and correct

Authority:

QMC Hub - ACC Injury Claim

Patient Declaration