Please complete this form if you need to advise ACC of a transfer.
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 *
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.