Income Protection Claim Form (AIA New Zealand) Completed Form Examples and Samples
View a detailed example of a completed AIA New Zealand Income Protection Claim Form. This sample provides a clear guide on how to fill out the form correctly, helping you understand the required information for a successful claim.
AIA New Zealand Income Protection Claim Form Example
How this form was filled:
This is a sample of a completed AIA New Zealand Income Protection Claim Form. The use case is for a Senior Software Developer who has suffered a back injury (herniated disc), making them unable to perform their job. The form includes personal details, policy information, a description of the injury, and details of their medical provider and employer.
Information used to fill out the document:
- Claimant's Full Name: Liam O'Connor
- Policy Number: IP-987654321
- Date of Birth: 1988-05-15
- Address: 45 Queen Street, Auckland, 1010, New Zealand
- Occupation: Senior Software Developer
- Employer: Tech Solutions NZ Ltd.
- Nature of Illness/Injury: Herniated disc (L4-L5) causing severe lower back pain and sciatica
- Date Injury/Symptoms First Occurred: 2026-03-10
- Last Day at Work: 2026-03-10
- First Day Unable to Work: 2026-03-11
- Attending Doctor's Name: Dr. Emily Carter
- Medical Practice: Auckland Spine & Sports Clinic
- Date of Claim Form Submission: 2026-04-01
What this filled form sample shows:
- Accurate completion of claimant's personal and policy details.
- Clear description of the illness/injury and how it impacts work duties.
- Inclusion of attending doctor's information for medical verification.
- Precise dates for the last day of work and the start of the disability period.
Form specifications and details:
| Form Name: | Income Protection Claim Form |
| Provider: | AIA New Zealand |
| Use Case: | Claim for disability due to back injury preventing work |
| Jurisdiction: | New Zealand |
Created: February 12, 2026 07:30 PM
