Acc 855 Form PDF Details

The ACC 855 form is a comprehensive application utilized by individuals and businesses in New Zealand seeking to opt into ACC CoverPlus Extra, a customizable version of the standard ACC coverage that offers tailored benefits and compensation for injuries sustained during work. Within its sections, the form gathers detailed applicant information, including ACC and IR numbers, contact details, and specific business structure categorization, whether one operates as a sole trader, is part of a partnership, or functions as a shareholder-employee. Also outlined are the roles of accountants who may act as primary contacts, alongside provisions for individuals completing the form on behalf of an applicant. The form delves into the intricacies of business operations, asking for trading names, established dates, types of business, and a breakdown of tasks alongside earnings liable for ACC contributions. For partnerships and corporations, it requests additional information about partners or shareholder-employees, including their decision to apply for ACC CoverPlus Extra and the financial intricacies of their contributions. Furthermore, it delineates the cover details that applicants can choose from, based on their individual requirements and expectations regarding weekly compensations and levy contributions. It ends with a declaration section emphasizing the importance of accuracy in the information provided and the implications of the Privacy Act 1993 on the handling of submitted details. The ACC 855 form is thus pivotal for understanding the tailored insurance options available for diverse business structures and ensuring the right level of cover and compensation following workplace injuries.

QuestionAnswer
Form NameAcc 855 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesacc coverplus extra application, YYYY, FTEs, 1982

Form Preview Example

ACC

855

ACC CoverPlus Extra

Application form

Section 1 – Applicant details

ACC number:

Check last year’s ACC invoice or ask your accountant

IR number:

Title:

First name:

Last name:

Date of birth:

Postal address:

Mr

Mrs

Miss

Ms

Dr

DD

MM

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suburb

 

 

 

 

 

 

City + Postcode

Email address:

Phone:

Phone:

Other:

 

Area code

 

Work number

 

 

 

 

 

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area code

 

Home number

 

 

 

 

 

 

 

 

 

 

 

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

Other number

 

 

 

 

 

 

 

 

 

 

 

 

 

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 2 – Accountant details

Accountant’s name:

Accountancy firm:

Accountant’s email:

Accountant’s contact

 

Area code

 

Business number

 

 

phone number:

 

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3 – Applying on behalf of applicant

My accountant should be the primary contact

Yes

No

Completing on behalf of applicant?

 

No – Go to section 4

 

Yes – Please fill in your details below

Your name:

 

 

 

 

Your relationship:

Your email address:

Your contact number:

Area code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary contact?

 

Yes

 

No

 

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 4 – Business structure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business structure:

 

Self-employed – sole trader

 

– Please fill in section 5, 8 and 9

 

 

 

 

 

 

 

 

 

 

 

 

Self-employed – partnership

 

– Please fill in section 5, 6, 8 and 9

 

 

 

 

 

 

 

 

 

 

 

 

 

Shareholder-employee

 

– Please fill in section 7, 8 and 9

 

 

 

 

 

 

 

 

 

 

 

Definition of business structures

A sole trader is a person trading on their own, entitled to all profits and personally liable for all business debts.

A partnership is the relationship existing between two or more persons who agree to carry on a trade or business. They share in the profits and are personally liable for losses of the business.

A shareholder-employee is someone who owns part or all of a company and also works for the company. Shareholder-employees are not personally liable for debts of the company. Please refer to your accountant or contact us if you require further assistance.

January 2014

Section 5 – Self-employed details

Part A

Your trading name:

Date established in business:

Type of business:

DD

MM

YYYY

Use the ACC classification description. Ask your accountant or check your ACC invoice

Business classification number:

How many hours per week do you work:

Main work tasks performed by you, and estimate of time spent/ percentage of earnings from each:

Use the ACC classification number. Ask your accountant or check your ACC invoice

Please provide an accurate estimate of the average hours

Hours

Hours

Hours

%$

%$

%$

Has your business classification number changed in the last three years?

 

No – Go to part B

 

Yes – Please complete information below

Previous business classification number:

Date of change:

DD

MM

YYYY

Reason why your business classification number changed:

Part B

Your self-employed earnings that were liable for ACC payments in the last three tax years:

 

DD

 

 

MM

 

 

YYYY

 

 

 

 

 

 

 

 

3

 

1

0

 

3

2

 

0

 

 

 

 

 

 

DD

 

 

MM

 

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

1

0

 

3

2

 

0

 

 

 

 

 

 

DD

 

 

MM

 

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

1

0

 

3

2

 

0

 

 

 

 

 

$

$

$

Section 6 – Business partner’s details

Number of partners in

 

 

Your share of the

%

 

your business:

 

 

 

 

 

 

 

 

business income:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is your partner/s applying for ACC CoverPlus Extra?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, their application should be attached and sent with this form. If no, please supply the following details:

Partner’s

ACC number:

Partner’s

ACC number:

Partner’s

ACC number:

Is your partner categorised as a ‘passive earner’?

 

Yes

Partner’s

IR number:

Partner’s

IR number:

Partner’s

IR number:

No

A passive earner is a person who has no physical or mental input into the running of the business, therefore their earnings are not liable for ACC. Ask your accountant or Inland Revenue if you are unsure.

Section 7 – Shareholder-employee details

If you are a shareholder-employee and receive PAYE deducted salary from your own company you are NOT eligible for CoverPlus Extra. Have you received PAYE deducted salary from your own company in the last five years?

No – Go to part A

Yes – Please complete the date you ceased receiving PAYE (then go to part A)

DD

MM

YYYY

Part A

Your trading/company name:

Company

ACC number:

Date established

DD

MM

YYYY

in business: Type of business:

Company IR number:

Use the ACC classification description. Ask your accountant or check your ACC invoice

Business classification number:

Use the ACC classification number. Ask your accountant or check your ACC invoice

Has the company’s business classification number changed in the last three years? No – Go to part B

Yes – Previous Business Classification

Date of change:

DD

MM

YYYY

Reason why the company’s business classification number changed:

Part B

What type of goods or services does the company provide?

Who is a typical customer of your company?

How many hours per week do you work:

Main work tasks performed by you, and estimate of time spent/ percentage of earnings from each:

Please provide an accurate estimate of the average hours

Hours

Hours

Hours

%$

%$

%$

Your shareholder salaries that were liable for ACC payments in the last three tax years:

 

DD

 

 

MM

 

 

YYYY

 

 

 

 

 

 

 

 

3

 

1

0

 

3

2

 

0

 

 

 

 

 

 

DD

 

 

MM

 

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

1

0

 

3

2

 

0

 

 

 

 

 

 

DD

 

 

MM

 

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

1

0

 

3

2

 

0

 

 

 

 

 

$

$

$

Number of shareholder-

Your share of the

 

 

 

 

 

%

 

employees in your

 

 

 

 

 

 

 

 

business income:

 

 

 

 

 

 

business:

 

 

 

 

 

 

 

 

 

 

 

 

Is any other shareholder-employee applying for ACC CoverPlus Extra?

 

 

Yes

 

 

No

If yes, their application should be attached and sent with this form. If no, please supply the following details:

Shareholder-

Shareholder-

employee’s

employee’s

ACC number:

 

 

 

 

 

 

 

 

 

IR number:

Shareholder-

Shareholder-

employee’s

employee’s

ACC number:

 

IR number:

Shareholder-

Shareholder-

employee’s

employee’s

ACC number:

 

 

 

 

 

 

 

 

 

IR number:

 

Section 8 – Cover details

Choose which option you require:

ACC CoverPlus Extra

Provides 100% weekly compensation until you return to work full-time. Weekly compensation is not reduced as you return to work part-time.

ACC CoverPlus Extra with Lower Levels of Weekly Compensation

For a slightly reduced work levy, your weekly compensation reduces when you return to work part-time or if your business continues to generate income. Only available if you work full-time.

Annual ACC CoverPlus Extra you’re applying for:

(Please note maximums and minimums apply, may be subject to underwriting approval)

Effective start date:

(Your policy will be effective from your elected start date, or the date ACC receives this form – whichever is the latest.)

$

DD

MM

YYYY

If you’re applying for cover that is significantly more than you earned last year, please tell us why:

What happens now?

•Please make sure all relevant sections are filled in or your application may be withdrawn.

•Once your application has been processed (may be subject to underwritting approval), we will send you an offer that must be signed and returned to us. You (the applicant) must sign the offer. It can not be signed by an authorised person.

•The start date of your policy will be back dated to the date ACC received your application so if we have not processed your application and you sustain an accidental injury during that period, we will review on a case-by-case basis the amount of weekly compensation you are entitled to.

Section 9 – Declaration

We recommend you obtain professional independent advice relevant to your individual circumstances before signing this form.

•I understand that the information ACC collects on this form will be used in accordance with the Privacy Act 1993 to process this application for an ACC CoverPlus Extra policy.

•I understand that in collecting, using and storing this information, ACC will at all times comply with the guidelines of that Act.

•I understand that this authority relates to all aspects of my policy and authorises ACC to contact anyone who holds relevant information, including any external agencies or service providers. I have the right to see, and ask for correction of, any information that ACC holds about me.

•I understand that I am giving my Representative, Tax Agent, Accountant or Financial Advisor (Agent or Advisor) authority to access and change my ACC account by telephone, email, letter, fax, form or ACC online services.

•I understand that by providing my authority to an Agent or Advisor, I am providing authorisation to the Agent or Advisor Organisation and each representative within that organisation.

•I authorise the collection and release of any information about me to the extent that it is needed to determine cover and/or assess my entitlement to compensation.

•I declare that the information supplied on this form is true and correct and that I have not withheld any information likely to affect my application. I will inform ACC of any change in circumstances that may affect my entitlements. I have read and understood the Privacy Act 1993 information above.

Your name:

(please print)

Your signature:

Date:

DD

MM

YYYY

NOTE: If you are completing this form on behalf of the applicant and it has been signed by you and not the applicant, please ensure that you have full authorisation on the applicant’s account. If not please ensure you have completed an “ACC1766 Giving access to your levy information” and attach it to this application. A copy is available on our website at www.acc.co.nz.

In the collection, use and storage of information ACC will at all times comply with the obligations of the Privacy Act 1993 and the Official Information Act 1982.

Please return to ACC Business Service Centre, PO Box 795, Wellington 6140

For assistance freephone 0508 426 837 or email business@acc.co.nz

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As a way to finalize this document, ensure that you enter the necessary details in each blank field:

1. When submitting the coverplus extra application, make certain to incorporate all necessary blank fields within its relevant section. It will help to speed up the process, allowing for your information to be processed promptly and appropriately.

Filling out segment 1 in 1982

2. After performing the last section, go to the subsequent step and fill out all required particulars in these blanks - Other number, Other, Code , Section Accountant details, Accountants name, Accountancy firm, Accountants email, Accountants contact phone number, Area code, Business number, Section Applying on behalf of, My accountant should be the, Yes, Completing on behalf of applicant, and No Go to section .

Find out how to prepare 1982 portion 2

3. This step is normally simple - fill in all the form fields in Your email address, Your contact number, Area code, Section Business structure, Primary contact, Yes, Business structure, Selfemployed sole trader, Please fill in section and , Selfemployed partnership, Please fill in section and , Shareholderemployee, Definition of business structures, Please fill in section and , and January to complete the current step.

1982 writing process outlined (stage 3)

4. Completing Part A Your trading name, Date established in business, Type of business, Business classification number, How many hours per week do you work, Main work tasks performed by you, YYYY, Use the ACC classification, Use the ACC classification number, Please provide an accurate, Hours, Hours, Hours, Has your business classification, and No Go to part B is paramount in this stage - make sure to invest some time and fill out each and every blank area!

Learn how to prepare 1982 stage 4

5. The last step to complete this document is essential. Ensure you fill in the appropriate blank fields, for instance Part B, Your selfemployed earnings that, DD , DD , DD , YYYY , YYYY , YYYY , Section Business partners details, Number of partners in your business, Your share of the business income, Is your partners applying for ACC, Yes, If yes their application should be, and Partners ACC number, prior to using the form. Neglecting to do this can contribute to an unfinished and probably incorrect paper!

YYYY , DD , and YYYY of 1982

In terms of YYYY and DD , be certain that you review things here. Both these are the most important ones in the form.

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