Application for lump sum / independence allowance




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ACC54

Application for lump sum / independence allowance


Fill in this form to apply for a lump sum payment or an independence allowance. When you’ve finished, return it to us using the enclosed reply-paid envelope, or scan and email it and any supporting documents to IALS@acc.co.nz.

You can use the checklist in section 5 to make sure you’ve included everything you need to, such as a bank statement and your medical certificates.



1. Your details

Your name: [Client full name auto]

Your client number: [Person ID auto]

So that you get the right payments, we need to check if you’ve previously had a claim with us under another name. If you’ve ever been known by any other names, what are they?      


Your phone numbers:

Home:      

Work:      

Mobile:      

Your address:      






2. Alternative contact person

If it makes things easier for you, you may want your partner or a relative or parent to be able to talk to us about the questions on this form, what happens next or what payments you may be entitled to.

Would you like to give us permission to talk to someone else about your application for a lump sum payment or independence allowance?

 Yes  No

If Yes, please give us the full name, address and phone number of this person and their relationship to you.

If No, go to section 3.



Full name:      

Contact phone number:      

Address:      


Email address:      

What’s their relationship to you?      

Please describe anything you do not want us to talk to this person about:      





3. Collecting your relevant medical and other records

Who holds medical records about your current injury(s)?      

Why we ask for your authority to collect your medical and other records

To establish your entitlement to compensation we may need to collect medical and other records about you from a third party, such as your General Practitioner (GP), other medical professional or employer.



We need your authority to collect them

These records could include:

medical reports

details of your accident

medical history relevant to your claim

specialist reports and assessments

your employment details and history.

In each case, we’d only seek records that are or may be relevant to your claim during the life of your claim.

We’ll let you know about the types of records we need to collect, and why we need to collect them to make these decisions about your claim. Please contact us if you’d like to discuss this further.

How you can provide your authority

You can either sign this form or contact us if you’d like to discuss other ways to provide your authority. These may include for example, setting the duration of your authority or asking us to contact you for authority on a case by case basis.



We’ll comply with the legislation

We’ll comply with the Privacy Act 1993, the Health Information Privacy Code 1994 and the Accident Compensation Act 2001 when collecting, using and managing personal information.

Under the Privacy Act 1993 and Health Information Privacy Code 1994, you have the right to access any information we hold about you. You can also ask us to correct the information that we hold about you.

For more details see ACC’s privacy notice at www.acc.co.nz/privacy.






4. Your declaration and authorisation

I confirm that to the best of my knowledge, all the information I have provided on this form is true and correct. I authorise ACC to collect relevant medical and other records to help make decisions about my application for a lump sum payment or an independence allowance.

Print your name:      

Date:      

Your signature (or your legal guardian’s or representative’s):      




5. Application checklist

Please tick the boxes below to confirm that:



you’ve completed all the questions



your medical provider has completed the relevant medical certificates for the injury(s) you’d like us to consider in this application, and:

 you’ve enclosed them with this form. If so, how many medical certificates have you enclosed?      



or

 your medical provider is going to send us the relevant medical certificates





you’ve attached a bank statement, deposit slip or a stamped and signed document from your bank that shows your bank account name and number



you’ve read section 3 and signed section 4

When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy Code 1994. For further details see ACC’s privacy policy, available at www.acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001.

ACC54 August 2015 Page of 2


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