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.
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: | VA claim forms, income forms |
| Created: | February 12, 2026 07:17 PM |