Payment plan via direct debit
ACC1768 August 2021
Section  – Declaration
Return both pages via email to at least 10 days before the due date of your levy. If you have any questions about completing this
form, contact us on 0800 222 776, by emailing the above address or live chat via your online portal account.
Use this form to pay your ACC levies by direct debit or sign up for MyACC for Business and arrange online. Register now at
Mandatory elds
Section a – Your account details
Contact phone numbers:
Number (mobile)
Area code
Number (landline)
ACC account name:
Postal address:
Street address or PO Box number
Email address:
City + PostcodeSuburb
ACC number:
Or IR / NZBN number:
All future ACC levy communication will be sent to the email address above.
Date of birth:
Section b – Delegated Authority
It is compulsory to complete section 1b if the ACC account is for a non-individual (e.g. a company/partnership) or if you are not the individual ACC
account holder. Providing access to ACC levy account information form will also be required if not yet authorised.
Your name:
Your position/relationship to
account holder/designation:
Section  – Payment details
Tick here if you are only advising ACC of a change in your bank account number. Do not complete the rest of section 2 if current plan is not to be amended.
Annual payment on the due date OR pay monthly over 3 months 6 months
10 months
If no option is selected, we will set up your invoice(s) on a 10-month plan. 10 -month payment plans will incur a 2.73% administration fee.
If you have a preference, please specify the date in the month you would like your payments to be deducted, e.g. the 20
The information on this form is true and correct to the best of my knowledge.
I have read, understood and agreed to the terms and conditions on page 2 of this form.
I understand that ACC will use this payment instruction for any future payments unless otherwise advised.
I have authority to submit this form.
Your signature:
Direct debit authority
Please reactivate my previously cancelled direct debit authority.
This section must be filled in by the bank account holder(s) who have signing authority.
Name of my bank account:
Name of my bank:
My bank account number:
BranchBank Account number Sux
From the acceptor to their bank:
I authorise you to debit my account with the amounts of direct debits from the Accident Compensation Corporation with
the authorisation code on this authority in accordance with this authority until further notice.
I agree that this direct debit authority is subject to:
The bank’s terms and conditions that relate to my account
The specic terms and conditions listed on the reverse of this form
Having signed authority on this bank account
Authorised signature(s)
Print name(s) of signatory(s)
Authorisation Code
Terms and conditions of paying by direct debit
Regular payments and method
1. ACC will send you a payment schedule showing the payments to be paid and the due date for each payment.
2. All payments under this agreement must be by direct debit to ACC’s bank account.
3. If a payment is due on a non-business day, please refer to your payment schedule.
4. The levy can be paid annually or in 3, 6 or 10 monthly payments. You are required to choose the length of the payment plan in
Section 2: Payment Details.
Administration fee
5. If you choose to pay your levy in 10 equal monthly payments, you must pay an administration fee of 2.73% of the total annual levy amount. This fee
will be added to your monthly payments, as set out in your payment schedule. The administration fee rate may be changed by ACC
by giving at least 30 days’ notice.
Early repayment
6. You may pay the full levy amount at any time during the year. If you wish to do this, but have elected to pay the levy in 10 equal monthly payments,
you will need to contact ACC to request that the administration fees be adjusted to reect the early payment of the full levy amount.
CoverPlus Extra
7. If you are a CoverPlus Extra policy holder, and do not pay by the date required under your planned agreement, your policy and the planned
agreement will be terminated immediately. You will then receive ACC’s standard cover policy and be required to pay levies for the period that the
standard cover applies.
Missed instalment payments, penalty interest and other expenses (does not apply to CoverPlus Extra policies).
8. If any payments are not paid to ACC on the due date then ACC may cancel the payment plan at any time, and you will be liable to pay the
remaining balance of the levy.
9. For any payment that you do not pay to ACC by the due date, you must pay ACC interest on the payment at the rate of 1% per month, compounded
monthly. You will be charged interest from the due date of the payment to the date you pay ACC the payment, and any interest and penalties
owing, in full. Interest is charged in accordance with sections 250(1) to (3) of the Accident Compensation Act 2001. The maximum amount you must
pay to us in respect of any payment due, including penalty interest, is three times the amount of the payment not paid.
10. If ACC incurs any costs (such as internal and external costs and/or legal fees) in recovering money you owe or in enforcing its rights under this
agreement, you must pay these on demand.
Future levy payments
11. ACC will use the information you have provided to arrange future levy policies by roll over plan or annual direct debit payment.
Information collection
12. ACC collects information about you to administer your levy account and to manage levies paid by you. If debt collection is necessary, ACC’s
employees or contractors may be given access to your information to undertake debt collection. If ACC engages another party to undertake debt
collection, that party will also be given access to your information.
Conditions of the Direct Debit Authority
Specic conditions relating to notices and disputes
You may ask your bank to reverse a direct debit up to 120 calendar days if:
You don’t receive a written notice of the amount and date of each direct debit from the initiator, or
You receive a written notice but the amount or the date of debiting is dierent from the amount or the date specied on the invoice
The initiator is required to give a written notice of the amount and date of each direct debit in a series of direct debits no less than 10 calendar days
before the date of the rst direct debit in the series. The notice is to include:
The dates of the debits, and
The amount of each direct debit.
If the initiator proposes to change an amount or date of a direct debit specied in the notice, the initiator is required to give you notice no less than
30 calendar days before the change.
For direct debits with notice no later than the date of the debit, the initiator may only send a direct debit if you have:
Asked the initiator to send it, and
Agreed the amount of the direct debit.
For customer-initiated payments, the initiator is required to give you a written notice of the amount and date of each direct debit no less than the
date of the debit.
In the collection, use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 2020, the Ocial Information Act 1982 and
the Health Information Privacy Code 2020.
ACC1768 August 2021