ACC33 Review application

Fill in this form if you want to independently review a decision we’ve made about your claim or your levies.

About this formBefore you fill in this form, please read the following information.

You need to apply for a review within three months from the date of our decision letter. If you’re unable to meet this timeline, please get in touch with us so we can talk about it. We are unable to extend review timeframe for levy or employer decision reviews.

It’s important to fill in all the sections of this form, including signing and dating the declaration. We may return the form to you if there is any missing information.

If you need any help with this form, please contact the person at ACC who has been helping you with your claim or levies, or contact us on 0800 101 996.

Returning this formWhen you’re finished with this form, please return it to accreviewapplication@acc.co.nz or ACC Resolution Services, PO Box 892, Waikato Mail Centre, Hamilton 3240.

1. Client/Customer details

Client/Customer name:       (Optional) Organisation name:      

Claim or ACC number:       Telephone number:      

Address:      

Postal address (if different from above):      

Email address:      

2. Primary contact for this application

Use contact details in Section 1: Use contact details of the person below:

Name:       Telephone number:      

Email address:       Authority to Act attached: Yes

Relationship to the review applicant:      

3. Cultural support services

You have the right to:

whānau, kaumātua or family support to be present interpreters, if required, for you or your support person(s) have your review hearing at an appropriate community venue, if possible.

Please contact me about cultural support services.

4. Decision date

What’s the date of the decision letter, or the date you received the advice that you want reviewed?      

6. DocumentsWe’ll work with you to identify all documents which are relevant to your review and how we will deliver them to you. These documents will also be given to your reviewer.

7. Declaration and signature

I confirm that to the best of my knowledge:

I am authorised to apply for this review The information I’ve provided on this form is true and correct.

Signature:       Today’s Date:     

When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy Code 1994. For further details see ACC’s privacy policy, available at www.acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001

ACC33 July 2019 Page

5. The review reasons

Please explain the reasons you would like to review our decision. Include any information that supports your application. You can attach extra pages if you like.      

What is your ideal outcome?      

If you’re applying to review a decision more than three months since the date of the decision, please explain why you were unable to apply earlier. You can include information that supports your reasons.