I Authorise ACC to Carry out Or Initiate Transactions in Accordance with This Authority
If you would like to authorise someone to act on your behalf complete and return this form
Section 1 your contact details
ACC number / IRD number / n/a
Company Name
Name & Position
Postal Address / Phone
Postal Address / Fax
Postal Address / Mobile
Postal Address / Email
Section 2 Giving access to an Agent
I authorise the following organisation and its representatives to access my ACC levy account information
Name / Fucultas Limited t/a ManageACC
Main Representative / Martin Wouters / Phone / 0800 RISK NZ
Postal Address / PO Box 5299 / Fax
Postal Address / Mt Maunganui 3150 / Mobile / 021 322 286
Postal Address / Email /
Access and change information through ACC Online and directly with ACC Staff: This will allow your named main representative to access and change your ACC levy account online and at their discretion delegate access to your information to other members of the organisation. This will also allow each member of the organisation to query and change your ACC levy account information through ACC staff.
Section 3 Other representatives
Name / Relationship / Phone Number / Access & change
Not applicable
Section 4 Postal information
Do not change postal information.
Section 5 Declaration
- I authorise ACC to carry out or initiate transactions in accordance with this authority.
- I understand that ACC is not liable for any action done in accordance with this authority.
- I understand that this authority comes into effect from the date the ACC Business Service Centre receives and processes this form.
- I understand that by providing authority to an Agent organisation I am providing authorisation to each representative within that organisation.
- I understand that I am giving my representative authority to access my account by telephone, email, letter, fax, form or as indicated in section 2 of this form.
- I understand that the cancelation of this authority must be made in writing or by telephone. It will not be effective until received by the ACC Business Service Centre.
- I understand that information provided on this form will only be issued 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.
- I understand that ManageACC and Manage Company will treat all information with utmost confidentiality.
Your signature / Date / 2015
ManageACC does not make any changes to your account without your specific approval
ACC Levy Questionnaire
- Business Name:
Shareholders
- List the shareholders who work in the business and get a wage / salary. If you receive income from more than one source (i.e. other companies) please list these.
Shareholders / Job Description / Level of Remuneration
$
For the following please circle the correct answer
- Do the shareholders take a wage or shareholder salary or both – please circle
Wages (with PAYE)Shareholder Salary (no PAYE)Both
- Do the shareholders have ACC Cover Plus Extra Policies?YesNoNot Sure
- Do the shareholders have income protection insurance? YesNoNot Sure
- Will the shareholders still get paid if they have an accident? YesNoNot Sure
- Do the shareholders earn a wage / shareholder salary from any other business?Yes No
- Do any shareholders receive Super as well as a wage?Yes No
Business Levy Code
- What does the business do?
% of income
- How many staff? Labour______Administration______
- Is there a standalone administration business / trust?YesNo
Accidents
- If you have any claims on your invoice do you agree with them?YesNoNot Sure
- Have there been any workplace accidents in the last 12 months? YesNoNot Sure
Health and Safety
- Is the business currently in the WSD or WSMP discount scheme?WSD WSMP Neither
- If neither, do you currently have a working health & safety system? YesNoNot Sure
Other
- What ACC payment plan are you in?10 month 6 month Pay in one lump other
Please return to ManageACC on or fax 07 929 7625
This information is kept strictly confidential