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ACC5636 - Business Grouping update form

ACC5636 - Business Grouping update form


Please complete this form if you have any Business Grouping changes to advise ACC.

If you have any questions about completing this form, contact your ACC Account Manager or the ACC Business Service Centre on Freephone 0800 222 776.

Mandatory fields are marked with an asterisk *

Group number

Please provide your group number as provided to you by ACC
Group number:*
Are you the Group Administrator for this group?

Have your contact details changed?

Group Member information - this is for changes only

Please advise any updates and indicate if the Group Member is to be added or removed from the group and provide any comments in the box provided below.

Please ensure you provide all ACC numbers (which must include the suffix) for each Group Member. If this information is not provided we may be unable to include your changes.

Add or Remove Business Name ACC Number
Add Remove
Add more lines

Comments*

Please provide comments and/or information that supports your Grouping updates. Also if you have supporting documentation that supports your Grouping updates please provide this in an email addressed to ergrouping@acc.co.nz

Disclaimer / Terms and Conditions

I declare that the information contained in this form is true and correct, and that ACC is authorised to verify this information.

I understand that this information will need to be reconfirmed at a later date.

I understand that the information provided on this form will only be used 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.
*
By making this declaration you agree that you are an authorised Group Administrator or someone else authorised to act on behalf of the Group Administrator.