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ACC5863 - Business Transfer form

ACC5863 - Business Transfer form

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 *

Contact Details

Please advise your contact details
Name *
Email address *
Phone number *
Street/PO Box number *
Suburb
City/Town *
Country (if not NZ)
Post Code *
Please indicate if you are the seller or buyer

Transfer information

Employer Details
Transferred Business's ACC Number *
Transferred Business's Name
Buyers Name
Buyer's Address
Street/PO Box number
Suburb
City/Town
Country (if not NZ)
Post Code
Transfer Date
Date the business transfer is effective from

Comments*

Please provide any comments, information relating to this transfer. Also if you have supporting documentation that supports this transfer please provide this in an email addressed to ergrouping@acc.co.nz

Payroll details associated with the business being transferred

Classification unit/s (or BIC code/s) being transferred
Payroll associated with transferred business (Levy year is 1 April to 31 March)
Current levy year $
Preceeding levy year $
Preceeding levy year $
Preceeding levy year $

Claim details associated with the business being transferred


Please provide this information for the current and preceding three levy years
Claim Number/s
Claimant Name/s

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 have read and understood the terms and conditions and are someone authorised by the employer to provide this information.