I authorise ACC to carry out or initiate transactions in accordance with this authority.
I understand that ACC is not liable for any action done in accordance with this authority.
I understand that this authority comes into effect from the date ACC receives and processes this form.
I understand that by providing authority to an Agent or Advisor organisation I am providing authorisation to each representative within
that organisation.
I understand this will allow my representative to access and make changes to my ACC levy account.
I understand that I am giving my representative authority to access my account by telephone, email, letter, fax, form, and online.
I understand that the cancellation of this authority must be made in writing, online or by telephone. It will not be effective until received
byACC
I understand that the information provided on this form will only be issued to fulfil the requirements of the Accident Compensation Act
2001, and that ACC complies at all times with the Privacy Act 1993, and the Official Information Act 1982.
I have delegated authority to submit this form on behalf of a non-individual.
Your signature:* Date:
DD MM YYYY
You must notify us if you decide to cancel or change the access agreed to in this authority (see contact details below).
Please return by email to business@acc.co.nz or post to
ACC Business Service Centre, PO Box 795, Wellington 6140
For assistance phone 0800 222 776 or email business@acc.co.nz
In the collection, use and storage of information ACC will at all times comply with the obligations of the Privacy Act 1993 and the Official Information Act 1982.
Full name:*
Relationship:*
I authorise the following individual to access my ACC levy account information.
Postal address:*
Street
Suburb
Email address:*
Code Mobile number
0
Mobile:*
Phone:*
Area code Business number
0
City + Postcode
Section 3 – If giving access to other representatives (eg individuals)
Section 4 – Declaration
