ACC
1766
Giving access to your ACC levy information
If you would like to authorise a representative to access your ACC levy information,
complete and return this form. Or you can sign up for MyACC for Business and invite others
to access your ACC account. Register now at myacc.co.nz/forbusiness
ACC account name:*
Your position:
ACC number:* IR
number:
Continued …
August 2018
Your name:
Preferred name (if applicable):
Postal address:*
This must match your account. If
this has changed, please note in
section 1c.
New postal address:
Street
Street
City + Postcode
City + Postcode
Suburb
Suburb
Email address:
Phone:
Area code Business number
0
Code
Mobile number
0
Mobile:
or
ACC number:* IR
number:
I authorise the following organisation and its representative(s) to access my ACC levy account information.
ACC account name:*
Trading name:
Postal address:*
Street
Suburb
Email address:*
Code Mobile number
0
Mobile:*
City + Postcode
Phone:*
Area code Business number
0
or
* Mandatory fields
Section 1a – Your account details
Section 1b – If the account is for a non-individual
Section 1c – Your updated account details
If you have more than one ACC account, you will need to fill in a separate form for each
Complete the next two fields if the account you are giving access to is for a non-individual (e.g. a company). In doing so you are confirming
you have delegated authority to submit this form.
To add or update any details on your account, please note below:
Section 2 – If giving access to an Agent or an Advisor
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
byACC
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