CoverPlus Extra Application Form

Eligibility Check


Find out if you, or the person you are representing, can apply for ACC CoverPlus Extra.

You can use the ACC CoverPlus Extra Calculator to decide what options are best.

Self-Employed Sole Trader

A Self-Employed Sole Trader is a person trading on their own, entitled to all profits and personally liable for all business debts.


Self-Employed Partnership

A Self-Employed Partnership is the relationship existing between two or more persons who agree to carry on a trade or business. They share in the profits and are personally liable for losses of the business.


Shareholder-Employee

A Shareholder-Employee is someone who owns part or all of a limited liability (LTD) company and also works for the company. Shareholder-employees are not personally liable for debts of the company.


Please refer to your accountant or contact us if you require further assistance.


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No
Yes
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Sorry, CoverPlus Extra is only available to applicants who are involved in one or more of these business structures All structure options must be answered

Please only include the number of hours worked from self-employed, partnership and/or shareholder employee income.

If the applicant works irregular hours or days, part time or only part of the year then use the information you have to estimate how many hours per week the applicant would have worked if spread evenly over the year. For example if they work on average about 3 days per week, then enter 24 hours (3/5 of a 40 hour typical week). If they work 6 months a year then enter 20 hours (6/12 of a 40 hour week).

This is out of the range of 1 to 168 hours Required
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In order to be eligible for CoverPlus Extra the applicant cannot receive PAYE wages from a company you are a shareholder of.

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To continue with the application you will need to confirm the date the applicant will cease receiving PAYE wages. The policy can only start after this date.
The date you supply will be validated with Inland Revenue

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Sorry, it looks like you don't qualify for ACC CoverPlus Extra. However, you are still covered by the ACC CoverPlus product.

If you would like more information, please call us on 0508 426 837 or email business@acc.co.nz

ACC CoverPlus Extra is only avaliable for Non-PAYE customers.

If you intend to receive PAYE and you want to apply for CoverPlus Extra then you should seek independent advice.
If you would like more information, please call us on 0508 426 837 or email business@acc.co.nz

Required
Required

Please note, if you indicate you have signed authorisation and this is not lodged on the applicant’s ACC account, this application will be rejected.

You need signed authority to complete this form on behalf of the applicant. You will need to complete an Authorisation Form (PDF 679kb) and have it signed by the applicant before we can process the application.


You can attach a scanned copy of this later in the application process.


If no authorisation is submitted with this application, this application will be rejected.

We recommend you obtain professional independent advice relevant to the circumstances of the individual applying.

Self-employed details

Used for underwriting purposes to approve the cover you are applying for.

Required
Required

Useful questions to determine this: What kind of goods/services do you provide to customers? What activity do you do to generate income?

Characters left:
Required

You can find your Business Industry code by visiting the Business Description Website

Required Invalid BIC or CU Code
Characters left:


For example:
As an Office Administrator: completes bill payments, GST returns, bank reconciliations etc.

Required
%
This is out of the range of 1 to 100% Required

Partnership Details

Used for underwriting purposes to approve the cover you are applying for.

Required
Required

Useful questions to determine this: What kind of goods/services do you provide to customers? What activity do you do to generate income?

Characters left:
Required

You can find your Business Industry code by visiting the Business Description Website

Required Invalid BIC or CU Code
Characters left:

For example:
As an Office Administrator: completes bill payments, GST returns, bank reconciliations etc.

Required
%
This is out of the range of 1 to 100% Required
ACC/IRD number or Partners Full Name is required Please enter a valid number Required

A separate application form will need to be completed for each partner that is applying.

Shareholder-Employee Details

Company {{$index + 1}} Company {{$index + 1}} - {{shareHolder.companyNameSHE}}
Required
Required Please enter a valid number
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Required

A Trading Company is a company that is currently actively trading supplying goods or services to a customer.

A Holding Company is a company that exists for the sole purpose of owning assets. No salaries or wages will ever be filed through this company.

A Look-Through Company (LTC) is a kind of tax structure for New Zealand companies with limited liability, which allows the company in question to transfer its income and expenditure to its shareholders directly.

Required
Required

Used for underwriting purposes to approve the cover you are applying for.

Required

Useful questions to determine this: What kind of goods/services do you provide to customers? What activity do you do to generate income?

Characters left:
Required

You can find your Business Industry code by visiting the Business Description Website

Required Invalid BIC or CU Code
Characters left:
Characters left:

For example:
As an Office Administrator: completes bill payments, GST returns, bank reconciliations etc.

Required
%
This is out of the range of 1 to 100% Required

Other company Shareholder-Employees

ACC/IRD number or Partners Full Name is required Please enter a valid number Required

A separate application form will need to be completed for each shareholder-employee that is applying.

Cover Details


You can use the ACC CoverPlus Extra Calculator to decide what options are best.

With this option customers receive the full agreed compensation until they are fit to return to full-time work. This provides greater flexibility and certainty.

In return for a slightly lower levy, this option provides compensation which reduces when returning to part time work. The compensation stops when full time work resumes.

Lower Levels of Weekly Compensation (LLWC) is only available for people who work 30 hours per week or more (Full time).

Please select one cover type
$
This is out of the range of $29 453 and $102 776 Required
Required
Characters left:
UPLOAD – 10MB limit per attachment (maximum is 6 files).
Files to Upload
{{file.name}}
File too large: max 10MB Cannot upload this file type This is required.

Applicant Details

Required Please enter a valid number
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Required
Required
/ / Please enter a valid date This date is in the future
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The email address is invalid.
Please enter a valid phone number Required

Contact Details

Your Details (Completing on behalf of Applicant)

Required
Required
The email address is invalid.
Please enter a valid phone number Required

Required

Accountant Details

Required
Required
The email address is invalid.
Please enter a valid phone number Required

Required

Contact Details

Required
Required
The email address is invalid.
Please enter a valid phone number Required

Application summary


Please check your application before submitting. You can go back and edit if needed.

Eligibility Check Self-Employed Details Partnership Details Shareholder-Employee Details Cover Details Applicant Details Contact Details Declaration
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Declaration

We recommend you obtain professional independent advice relevant to your individual circumstances before signing this form.

By ticking this declaration you declare the following:


  • The policy holder understands that the information ACC collects on this form will be used in accordance with the Privacy Act 1993 to process this application for an ACC CoverPlus Extra policy.
  • The policy holder understands that in collecting, using and storing this information, ACC will at all times comply with the guidelines of that Act.
  • The policy holder understands that this authority relates to all aspects of this policy and authorises ACC to contact anyone who holds relevant information, including any external agencies or service providers. The policy holder has the right to see, and ask for correction of, any information that ACC holds about them.
  • The policy holder understands that they are giving their Representative, Tax Agent, Accountant or Financial Advisor (Agent or Advisor) authority to access and change their ACC CPX account by telephone, email, letter, fax, form or ACC online services.
  • The policy holder understands that by providing their authority to an Agent or Advisor, they are providing authorisation to the Agent or Advisor organisation and each representative within that organisation.
  • The policy holder authorises the collection and release of any information about them to third parties to the extent that it is needed to determine cover including earnings details or to assess their entitlement to compensation.
  • The policy holder will inform ACC of any change in circumstances that may affect their entitlements.
  • I declare that the information supplied on this form is true and correct and that I confirm that no information has been withheld that is likely to affect the application. I have read and understood the Privacy Act 1993 information above.
You must confirm to be able to submit the application

Please note if signed authorisation is not lodged on the applicant’s ACC account, this application will be rejected.

Please ensure you have attached an ACC Authorisation Form (PDF 679kb) to gain authority to act on the policy holder's behalf.


If no authorisation is submitted with this application, this application will be rejected.

Thanks, your application has been successfully submitted.

The reference number for this application is: #{{formReferenceNumber}}

Please note this down for your records. Keep this number handy if you would like an update on the application.

What happens next?

An email confirmation of your application will be sent to the primary contact (if an email address was provided).


  • If we require more information to process the application, we will contact the primary contact.
  • We will send a Policy Acceptance Form to the address provided once the requested level of cover has been approved.
  • The applicant must sign the Policy Acceptance Form. It cannot be signed by an authorised person.
  • Upon receipt of the Policy Acceptance Form we will then send an invoice for the effective period.
  • The policy will only be effective once the invoice is paid.

If we have not processed the application and the applicant sustains an accidental injury during that period we will review on a case-by-case basis the amount of weekly compensation the applicant is entitled to.

Details Eligibility Check Self-Employed Details Partnership Details Shareholder-Employee Details Cover Details Applicant Details Contact Details Declaration

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