Income Protection Claim Form (AIA New Zealand Limited) Completed Form Examples and Samples

Explore detailed examples and samples of a completed AIA New Zealand Limited Income Protection Claim Form. Our filled-out templates help you understand how to correctly complete the form for accidents or illness, ensuring a smoother claim process.
Income Protection Claim Form (AIA New Zealand Limited) has a moderate Form Complexity Index of 60/100 — Instafill’s AI completes it in under a minute.
Fill out form with AI
Download PDF Example
Field Instructions
Completed AIA New Zealand Income Protection Claim Form for a claimant with a non-work related leg fracture.

AIA Income Protection Claim Form Example – Non-Work Accident

How this form was filled:

This example shows a completed AIA Income Protection Claim Form for Sarah Chen, a Marketing Manager who is unable to work due to a skiing accident in June 2026. The form details the claimant's personal information, policy number, accident specifics, medical diagnosis, treating doctor's information, and employment details, demonstrating a clear and comprehensive submission.

Information used to fill out the document:

  • Claimant's Full Name: Sarah Chen
  • Policy Number: IP12345678
  • Date of Birth: 15 May 1990
  • Occupation: Marketing Manager
  • Employer: Future Forward Ltd.
  • Residential Address: 45 Queen Street, Auckland 1010, New Zealand
  • Contact Number: 021 123 4567
  • Email Address: [email protected]
  • Cause of Disability: Accident - Slipped while skiing and fractured right tibia
  • Date of Accident: 10 June 2026
  • Last Day at Work: 9 June 2026
  • First Day Unable to Work: 10 June 2026
  • Treating Doctor: Dr. James Wilson, Orthopaedic Surgeon
  • Medical Diagnosis: Comminuted fracture of the right tibia
  • ACC Claim Lodged: Yes
  • ACC Claim Number: ACC987654
  • Pre-disability Annual Income: NZD $95,000
  • Bank Account for Payment: Kiwi Bank, 38-9012-0345678-00
  • Claim Form Submission Date: 25 June 2026

What this filled form sample shows:

  • Clear identification of the claimant and their AIA policy number.
  • Specific details of the non-work-related accident, including the date, location, and nature of the injury.
  • Inclusion of comprehensive medical information: a precise diagnosis, the treating doctor's details, and the treatment plan.
  • Declaration of a corresponding ACC claim, which is a critical component for income protection claims in New Zealand.
  • Complete employment and income details necessary for calculating potential benefit payments.

Form specifications and details:

Form Name: Income Protection Claim Form
Provider: AIA New Zealand Limited
Use Case: Claim for a non-work related accident (fractured leg) resulting in temporary total disability.
Jurisdiction: New Zealand
Categories: income forms, VA claim forms
Created: February 12, 2026 07:17 PM
Completed AIA New Zealand Income Protection Claim Form for a claimant with a non-work related leg fracture.