Income Protection Claim Form (AIA New Zealand Limited) Instructions

Enter the job title or occupation you held immediately before your current illness or injury.

Describe the main duties and responsibilities your role involves, including typical tasks you performed.

Provide the usual number of hours you work in an average week.

Explain whether your job is available for you to return to and, if not, provide details about why and any barriers to returning.

Check this box if ACC is being claimed for the injury (and provide the ACC claim number in the adjacent field).

Check this box if ACC is not being claimed for the injury.

Enter the ACC claim number associated with this injury or incident as shown on your ACC documentation or correspondence. Fill only if 'ACC Being Claimed - Yes' is 'Yes'.

Check this box if you are receiving or will claim compensation from ACC for your current condition.

Provide the compensation amount received from ACC.

Please enter the name of the account holder.

Please provide the full name of the additional policy owner.

Please enter the date the additional policy owner signed.

Enter the code identifying your bank.

Enter the branch number of your bank account.

Enter your bank account number.

Enter the suffix for your bank account.

Enter the full name of the claimant.

Enter the full name of your current general practitioner (GP) who is treating or has treated you for this condition.

Enter the name of the medical practice, clinic or surgery where your current GP works.

Provide the email address for your current GP or their medical practice for contact regarding your claim.

Enter your medical diagnosis and a clear explanation of how that condition prevents you from working, including symptoms, functional limitations and any relevant dates or onset information.

Enter the name of the first entity you are involved in.

Enter the name of the second entity you are involved in.

Enter the day of the date you first sought medical attention for this illness/injury as two digits (e.g., 05).

Enter the month of the date you first sought medical attention for this illness/injury as two digits (e.g., 09).

Enter the year of the date you first sought medical attention for this illness/injury.

Enter the full name of the hospital where you spent any time for your current illness or injury. Fill only if 'Hospital stay for current illness/injury — Yes' is 'Yes'.

Check this box if you have spent any period(s) of time in hospital for your current illness or injury.

Check this box if you have not spent any period(s) of time in hospital for your current illness or injury.

Enter the life assured's street address including house or unit number and street name.

Enter the life assured's suburb or neighborhood for the address.

Enter the life assured's city or town for the address.

Enter the life assured's postal or ZIP code for the address.

Enter the life assured's primary home telephone number, including area or country code if applicable.

Enter the life assured's work or office telephone number where they can be reached during business hours.

Enter the life assured's mobile or cell phone number for direct contact.

Enter the day of birth as a two-digit number (dd).

Enter the month of birth as a two-digit number (mm).

Enter the year of birth as a four-digit number (yyyy).

Enter the life assured's primary email address for contact regarding this claim.

Enter the life assured's full legal name (given/first name, middle name(s) and surname) exactly as it appears on the policy documents.

Enter the day (two digits) of the date you were medically certified to reduce hours or go on restricted duties (dd).

Enter the month (two digits) of the date you were medically certified to reduce hours or go on restricted duties (mm).

Enter the year (four digits) of the date you were medically certified to reduce hours or go on restricted duties (yyyy).

Enter the day (DD) of the date when you were medically certified to cease work.

Enter the month (MM) of the date when you were medically certified to cease work.

Enter the year (YYYY) of the date when you were medically certified to cease work.

Check this box if you are receiving or will be claiming other compensation or income not listed above for your current condition/claim.

Enter the monetary amount for other compensation received.

Check this box if compensation or income for your current condition/claim is being or will be claimed from any other insurer policy or policies.

Enter the compensation amount received from any other insurer policies.

Provide the full name of the Life Assured.

Check this box if you consent to the disclosure of your claims information to ASB for the purposes of notifying ASB of issues or disputes arising in respect of your claim.

Check this box if you do not consent to the disclosure of your claims information to ASB for the purposes of notifying ASB of issues or disputes arising in respect of your claim.

Enter the date of consent.

Enter the full policy number for the insured person as shown on your insurance documents.

Enter the full legal name of the Policy Owner.

Provide the date the Policy Owner's signature was affixed.

Enter the day (dd) of the date when you reduced your hours or went on restricted duties.

Enter the month (mm) of the date when you reduced your hours or went on restricted duties.

Enter the year when you reduced your hours or went on restricted duties.

Check this box if, at the date of your disability, your salaried employment was full‑time and you received income from that full‑time position.

Check this box if, at the date of your disability, your salaried employment was part‑time and you received income from that part‑time position.

Check this box if, at the date of your disability, your salaried employment was seasonal and you received income from that seasonal position.

Enter the full name of the employer for the salaried job from which your income is derived. Fill only if 'Full-time', 'Part-time', 'Seasonal' is 'Yes' (any).

Provide the name of the primary contact person at the employer (for example a manager or HR representative). Fill only if 'Full-time', 'Part-time', 'Seasonal' is 'Yes' (any).

Enter the telephone number for the employer contact person so they can be reached about your employment and income. Fill only if 'Full-time', 'Part-time', 'Seasonal' is 'Yes' (any).

Check this box if you have previously suffered from the same or a similar illness or injury as the condition for which you are now claiming.

Check this box if you have never suffered from the same or a similar illness or injury as the condition for which you are now claiming.

Provide a clear description of any prior same or similar illness or injury, including dates or periods affected, diagnoses, treatment or surgeries received, names of treating practitioners or hospitals, outcomes and how the previous episodes relate to your current incapacity to work. Fill only if 'Have you ever suffered from the same or similar illness or injury - Yes' is 'Yes'.

Provide the full legal name of the second entity you are involved in.

Provide the full legal name of the third entity you are involved in.

Check this box if your self-employment income is received through a company (a corporate entity) at the date of your disability; if checked, complete the adjacent 'Name of Entity' and '% Profit share entitlement' fields.

Enter the full name of the company or legal entity through which you are self-employed (the entity associated with your self‑employment income). Fill only if 'Shareholder employee' is 'Yes'.

Enter the percentage of the company’s profits to which you are entitled from this entity at the date of your disability. Fill only if 'Shareholder employee' is 'Yes'.

Check this box if you are self-employed and work as a contractor (i.e., you earn income through contracting) at the date of your disability.

Check this box when your type of self-employment is not listed (e.g., not sole proprietor, contractor, shareholder employee, companies, partnerships, or trusts); then specify the entity name and your % profit share entitlement in the adjacent fields.

Enter the brief description of the 'Other' self‑employment type not listed among the checkboxes (e.g., consultant, freelancer). Fill only if 'Other (Please specify)' is 'Yes'.

Enter the legal or trading name of the entity associated with the 'Other' self‑employment type specified in the previous field. Fill only if 'Other (Please specify)' is 'Yes'.

Enter the percentage of profit share entitlement for the named entity (the portion of profits you are entitled to receive). Fill only if 'Other (Please specify)' is 'Yes'.

Check this box if, at the date of your disability, you were self‑employed as a partner in a partnership (i.e., your income was derived from a partnership); provide the partnership name and your % profit share in the adjacent fields.

Enter the full name of the partnership (entity) for which you hold a profit share entitlement. Fill only if 'Companies' is 'Yes'.

Enter the percentage of partnership profits to which you are entitled. Fill only if 'Companies' is 'Yes'.

Check this box if you are self-employed as a shareholder-employee of an entity at the date of your disability (provide the entity name and your % profit share entitlement in the adjacent fields).

Enter the name of the company or entity associated with the shareholder-employee (the registered or trading name). Fill only if 'Contractor' is 'Yes'.

Enter the percentage of profit entitlement allocated to the shareholder-employee for the named entity. Fill only if 'Contractor' is 'Yes'.

Check this box if, at the date of your disability, you are self-employed as a sole proprietor (you operate your business in your own name and are not incorporated).

Check this box if your self-employment income is received through a trust (i.e., you operate or receive income from a trust), and then provide the trust's name and your % profit share entitlement in the adjacent fields.

Enter the full name of the trust entity from which you receive self-employment income or entitlement. Fill only if 'Partnerships' is 'Yes'.

Enter the percentage of profit share entitlement you receive from this trust. Fill only if 'Partnerships' is 'Yes'.

Check this box if you are claiming or receiving any sick leave as compensation or income for your current condition or claim.

Enter the monetary amount of any sick leave compensation received.

Enter the full name of Specialist 1 as you want it to appear on records (e.g., given name and surname).

Enter the medical or professional specialty of Specialist 1 (for example, 'Cardiology' or 'Occupational Therapy').

Enter the email address for Specialist 1 so they can be contacted about the case or referral.

Enter the full name of the second specialist (first and last name as appropriate).

Enter the medical or professional specialty of the second specialist (e.g., Cardiology, Orthopedics).

Enter the email address for the second specialist where they can be contacted.

Enter the specific duties performed by the spouse or family member receiving a profit share.

Enter the percentage of time the spouse or family member spends on each duty.

Enter the first part of the third entity's name you are involved in.

Enter the second part of the third entity's name you are involved in.

Enter the full name of the person to whom information is to be released.

Enter the full address of the person to whom information is to be released.

Enter the phone number of the person to whom information is to be released.

Enter the email address of the person to whom information is to be released.

Check this box to authorize AIA New Zealand Limited to release and/or discuss your personal and health information, including medical or financial details, with the above-named person(s).

Enter the day (two digits) of the date you totally ceased work, as part of the dd/mm/yyyy date.

Enter the month (two digits) of the date you totally ceased work, as part of the dd/mm/yyyy date.

Enter the year (four digits) of the date you totally ceased work, as part of the dd/mm/yyyy date.

Check this box if you wish to use an existing premium direct debit account for benefit payments.

Check this box if WINZ payments (Government support) are being claimed for your current condition/claim.

Enter the total amount of WINZ payments or government support received.