This form contains 201 fields organized into 64 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
ACC Claim Details
Yes	Checkbox	Check this box if ACC is being claimed for the injury.
No	Checkbox	Check this box if ACC is not being claimed for the injury.
Reason for no ACC claim	Text	Provide a detailed explanation if you are not claiming ACC for the injury.
ACC Claim Number	Text	Enter the official claim number assigned by ACC.
ACC Case Manager Name	Text	Enter the full name of your assigned ACC Case Manager.
ACC Case Manager Phone Number	Text	Enter the direct phone number for your ACC Case Manager.
Address
Address Street	Text	Please enter the street number and name of the address.
Address Suburb	Text	Please enter the suburb of the address.
Address City	Text	Please enter the city of the address.
Address Postcode	Text	Please enter the postcode of the address.
Benefit Payment Account
Name of Account	Text	Provide the human-readable name for the bank account to which benefit payments should be made.
Bank Code	Text	Provide the bank code associated with the account where benefit payments should be made. Max length: 2 characters
Branch Number	Text	Provide the branch number associated with the account where benefit payments should be made. Max length: 4 characters
Account Number	Text	Provide the core account number for the account where benefit payments should be made. Max length: 7 characters
Suffix	Text	Provide the account suffix for the account where benefit payments should be made. Max length: 3 characters
Claimant Name
Claimant Name	Text	Enter the full name of the claimant.
Compensation Contact Details
Name of organisation	Text
Contact persons name	Text
Contact persons phone number	Text
Contact persons email address	Text
Consent Name of Life Assured
Consent Life Assured Name	Text	Enter the full name of the life assured who is giving consent.
Consent to ASB Claims Disclosure - Yes	Checkbox	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.
Consent to Disclose Claims Information to ASB
Consent to Disclose Claims Information to ASB - Yes	Checkbox	Check this box to confirm your 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.
Contact Details
Home Phone	Text	Enter the home phone number.
Work Phone	Text	Enter the work phone number.
Mobile Phone	Text	Enter the mobile phone number.
Current GP Details
GP Name	Text	Enter the full name of your current GP.
GP Medical Practice	Text	Enter the name of your current GP's medical practice.
GP Street Address	Text	Enter the street number and name of your current GP's practice.
GP Suburb	Text	Enter the suburb where your current GP's practice is located.
GP City	Text	Enter the city where your current GP's practice is located.
GP Postcode	Text	Enter the postcode of your current GP's practice.
GP Phone	Text	Enter the phone number for your current GP's practice.
GP Fax	Text	Enter the fax number for your current GP's practice.
GP Email Address	Text	Enter the email address for your current GP's practice.
Current Medications
Current Medications	Text	Please list all medications you are currently taking.
Date Medically Certified to Cease Work
Date Medically Certified to Cease Work - Day	Date	Enter the day of the date you were medically certified to cease work. Max length: 2 characters
Date Medically Certified to Cease Work - Month	Date	Enter the month of the date you were medically certified to cease work. Max length: 2 characters
Date Medically Certified to Cease Work - Year	Date	Enter the year of the date you were medically certified to cease work. Max length: 4 characters
Date of Birth
Date of Birth Day	Date	Enter the day of the individual's date of birth. Max length: 2 characters
Date of Birth Month	Date	Enter the month of the individual's date of birth. Max length: 2 characters
Date of Birth Year	Date	Enter the year of the individual's date of birth. Max length: 4 characters
Date of First Medical Assistance
Date of First Medical Assistance Day	Text	Enter the day the user first sought medical assistance for their current condition or claim. Max length: 2 characters
Date of First Medical Assistance Month	Text	Enter the month the user first sought medical assistance for their current condition or claim. Max length: 2 characters
Date of First Medical Assistance Year	Text	Enter the year the user first sought medical assistance for their current condition or claim. Max length: 4 characters
Date Totally Ceased Work
Day Totally Ceased Work	Date	Enter the day the user totally ceased work. Max length: 2 characters
Month Totally Ceased Work	Date	Enter the month the user totally ceased work. Max length: 2 characters
Year Totally Ceased Work	Date	Enter the year the user totally ceased work. Max length: 4 characters
Declaration Date
Declaration Year	Number	Enter the year of the declaration. Max length: 4 characters
Declaration Day	Text	Enter the day of the declaration.
Declaration Month	Text	Enter the month of the declaration.
Declaration Name of Life Assured
Declaration Name of Life Assured	Text	Please provide the full name of the Life Assured for this declaration.
Description of Illness or Injury
Description of Illness or Injury	Text	Provide a detailed description of the illness or injury.
Diagnosis Given
Diagnosis Given	Text	Provide the diagnosis that has been given for the illness or injury.
Duties Unable to Perform
Duties Unable to Perform	Text	Enter the duties that you are currently unable to perform.
Email Address
Email Address	Text	Provide your email address.
Employer Address
Employer Address Street	Text	Please provide the street name and number for the employer's address.
Employer Address Suburb	Text	Please provide the suburb for the employer's address.
Employer Address City	Text	Please provide the city for the employer's address.
Employer Address Postcode	Text	Please provide the postcode for the employer's address.
Employer Details
Employer Name	Text	Enter the full legal name of the employer.
Employer Contact Person	Text	Enter the name of the primary contact person at the employer's organization.
Employer Contact Number	Text	Enter the contact phone number for the employer.
Employment Type
Full-time	Checkbox	Check this box if your salaried employment is full-time.
Part-time	Checkbox	Check this box if your salaried employment is part-time.
Seasonal	Checkbox	Check this box if your salaried employment is seasonal.
Expected Date of Return to Full/Unrestricted Work
Expected Date of Return to Full/Unrestricted Work	Date	Please provide the expected date when you can return to full and unrestricted work duties.
Expected Date of Return to Light/Part-Time Work
Expected Return to Light/Part-Time Work Date	Date	Provide the expected date you were told you could return to light or part-time work duties.
Fifth Compensation Row
Fifth Other Compensation (Yes)	Checkbox	Check this box if you are claiming other compensation or income by way of regular payment or lump sum settlement.
Fifth Other Compensation (No)	Checkbox	Check this box if you are NOT claiming other compensation or income by way of regular payment or lump sum settlement.
Fifth Compensation Row Other Amount	Number	Enter the amount of other compensation or income.
Fifth Compensation Row Other Start Date Day	Date	Enter the day for the start date of other compensation or income. Max length: 2 characters
Fifth Compensation Row Other Start Date Month	Date	Enter the month for the start date of other compensation or income. Max length: 2 characters
Fifth Compensation Row Other Start Date Year	Date	Enter the year for the start date of other compensation or income. Max length: 4 characters
Fifth Compensation Row Other End Date Day	Date	Enter the day for the end date of other compensation or income. Max length: 2 characters
Fifth Compensation Row Other End Date Month	Date	Enter the month for the end date of other compensation or income. Max length: 2 characters
Fifth Compensation Row Other End Date Year	Date	Enter the year for the end date of other compensation or income. Max length: 4 characters
Fifth Compensation Row Other Specify	Text	Specify the type of other compensation or income.
Fifth Entity Details
Fifth Entity Name	Text	Please enter the name of the fifth self-employment entity.
Fifth Entity Profit Share Entitlement	Number	Please enter the profit share entitlement for the fifth self-employment entity.
First Compensation Row
First Compensation Row ACC Yes	Checkbox	Check this box if ACC compensation is being or will be claimed for your current condition/claim.
First Compensation Row ACC No	Checkbox	Check this box if ACC compensation is not being or will not be claimed for your current condition/claim.
First Compensation Row Amount	Number	Enter the amount of compensation for the first row.
First Compensation Row Start Date	Date	Enter the start date of the first compensation row. Max length: 2 characters
First Compensation Row Start Date	Date	Enter the start date of the first compensation row. Max length: 2 characters
First Compensation Row Start Date	Date	Enter the start date of the first compensation row. Max length: 4 characters
First Compensation Row End Date	Date	Enter the end date of the first compensation row. Max length: 2 characters
First Compensation Row End Date	Date	Enter the end date of the first compensation row. Max length: 2 characters
First Compensation Row End Date	Date	Enter the end date of the first compensation row. Max length: 4 characters
First Entity Details
First Entity Name	Text	Enter the name of the first entity for self-employment.
First Entity Profit Share Entitlement	Number	Enter the profit share entitlement for the first entity.
First Hospital Stay
First Hospital Name	Text	Please provide the name of the hospital for the first hospital stay.
First Hospital Admission Date Day	Text	Please enter the day of admission for the first hospital stay. Max length: 2 characters
First Hospital Admission Date Month	Text	Please enter the month of admission for the first hospital stay. Max length: 2 characters
First Hospital Admission Date Year	Text	Please enter the year of admission for the first hospital stay. Max length: 4 characters
First Hospital Discharge Date Day	Text	Please enter the day of discharge for the first hospital stay. Max length: 2 characters
First Hospital Discharge Date Month	Text	Please enter the month of discharge for the first hospital stay. Max length: 2 characters
First Hospital Discharge Date Year	Text	Please enter the year of discharge for the first hospital stay. Max length: 4 characters
First Policy Owner Details
First Policy Owner Full Name	Text	Enter the full name of the first policy owner.
First Policy Owner Signature Date Day	Text	Enter the day the first policy owner signed the document.
First Policy Owner Signature Date Month	Text	Enter the month the first policy owner signed the document.
First Policy Owner Signature Date Year	Text	Enter the year the first policy owner signed the document. Max length: 4 characters
First Policy Owner Full Name
First Policy Owner Full Name	Text	Enter the full name of the first policy owner.
First Policy Owner Signature Date
First Policy Owner Signature Day	Date	Enter the day of the first policy owner's signature.
First Policy Owner Signature Month	Date	Enter the month of the first policy owner's signature.
First Policy Owner Signature Year	Date	Enter the year of the first policy owner's signature. Max length: 10 characters
Fourth Compensation Row
Fourth Compensation Row - WINZ payments (Government support) - Yes	Checkbox	Check this box if you are claiming or will claim WINZ payments (Government support) as compensation or income for your current condition/claim.
Fourth Compensation Row - WINZ payments (Government support) - No	Checkbox	Check this box if you are not claiming or will not claim WINZ payments (Government support) as compensation or income for your current condition/claim.
Fourth Compensation Row WINZ Payment Amount	Number	Enter the total amount received from WINZ payments (Government support).
Fourth Compensation Row WINZ Payment Start Day	Text	Provide the day of the start date for WINZ payments (Government support). Max length: 2 characters
Fourth Compensation Row WINZ Payment Start Month	Text	Provide the month of the start date for WINZ payments (Government support). Max length: 2 characters
Fourth Compensation Row WINZ Payment Start Year	Text	Provide the year of the start date for WINZ payments (Government support). Max length: 4 characters
Fourth Compensation Row WINZ Payment End Day	Text	Provide the day of the end date for WINZ payments (Government support). Max length: 2 characters
Fourth Compensation Row WINZ Payment End Month	Text	Provide the month of the end date for WINZ payments (Government support). Max length: 2 characters
Fourth Compensation Row WINZ Payment End Year	Text	Provide the year of the end date for WINZ payments (Government support). Max length: 4 characters
Fourth Entity Details
Fourth Entity Name	Text	Enter the name of the fourth self-employment entity.
Fourth Entity Profit Share	Number	Enter the percentage of profit share entitlement for the fourth self-employment entity.
Full Name
Full Name	Text	Please provide the full legal name of the life assured.
Full Name of Life Assured
Full Name of Life Assured	Text	Please enter the full legal name of the life assured.
History of Similar Illness or Injury
Previous Similar Illness or Injury Details	Text	Provide full details if you have previously suffered from a similar illness or injury.
Income Status
Income Received Yes	Checkbox	Check this box if you have received income since ceasing work after not working in your business or occupation.
Income Received No	Checkbox	Check this box if you have not received income since ceasing work after not working in your business or occupation.
Income Details	Text	Provide full details of any income received if you have not been working in your business or occupation since ceasing work.
Involved Entity Names
First Involved Entity Name	Text	Enter the name of the first entity you are involved in.
Second Involved Entity Name	Text	Enter the name of the second entity you are involved in.
Third Involved Entity Name	Text	Enter the name of the third entity you are involved in.
Fourth Involved Entity Name	Text	Enter the name of the fourth entity you are involved in.
Fifth Involved Entity Name	Text	Enter the name of the fifth entity you are involved in.
Sixth Involved Entity Name	Text	Enter the name of the sixth entity you are involved in.
Job Availability Details
Job Return Details	Text	Provide details if your job is not available for you to return to.
Job Duties and Time Percentage
Duties Description	Text	Provide a detailed description of your exact job duties.
Time Percentage	Number	Enter the percentage of time spent on each duty.
Loss of Income Details
Loss of Income Explanation	Text	Provide a detailed explanation of how the illness or injury has caused a loss of income.
Medical Investigations Undertaken
Medical Investigations Undertaken	Text	Provide a description of all medical investigations that have been undertaken for the current condition or claim.
Monthly Loss of Income
Monthly Loss of Income	Number	Enter the monthly amount of income lost due to the illness or injury.
No Loss of Income Details
No Loss of Income Details	Text	Please provide details explaining why there has been no loss of income.
Occupation Prior to Ceasing Work
Occupation Prior to Ceasing Work	Text	Enter your occupation immediately prior to ceasing work.
Performable Duties
Performable Duties	Text	Enter the duties that you are currently able to perform.
Policy Number
Policy Number	Text	Enter the policy number for the life assured.
Retirement Protection Benefit
Retirement Protection Benefit IRD Number	Text	Please provide your Inland Revenue Department (IRD) number related to your Retirement Protection Benefit.
Retirement Protection Benefit KiwiSaver Scheme Details	Text	Please provide the details of your KiwiSaver scheme related to your Retirement Protection Benefit.
KiwiSaver Member: Yes	Checkbox	Check this box if you are currently a KiwiSaver member.
Other KiwiSaver Contribution Benefit Source	Text	Please provide details about any other source from which you are entitled to receive a KiwiSaver contribution benefit.
Second Compensation Row
Second Compensation Row: Any other insurance policy/policies (Yes)	Checkbox	Check this box if you are claiming compensation or income through any other insurance policy or policies for your current condition/claim.
Second Compensation Row: Any other insurance policy/policies (No)	Checkbox	Check this box if you are NOT claiming compensation or income through any other insurance policy or policies for your current condition/claim.
Second Compensation Row: Any Other Insurance Policy Amount	Number	Enter the total monetary amount received from any other insurance policy or policies.
Second Compensation Row: Any Other Insurance Policy Start Date Day	Date	Enter the day the other insurance policy or policies began. Max length: 2 characters
Second Compensation Row: Any Other Insurance Policy Start Date Month	Date	Enter the month the other insurance policy or policies began. Max length: 2 characters
Second Compensation Row: Any Other Insurance Policy Start Date Year	Date	Enter the year the other insurance policy or policies began. Max length: 4 characters
Second Compensation Row: Any Other Insurance Policy End Date Day	Date	Enter the day the other insurance policy or policies ended. Max length: 2 characters
Second Compensation Row: Any Other Insurance Policy End Date Month	Date	Enter the month the other insurance policy or policies ended. Max length: 2 characters
Second Compensation Row: Any Other Insurance Policy End Date Year	Date	Enter the year the other insurance policy or policies ended. Max length: 4 characters
Second Entity Details
Second Entity Name	Text	Enter the name of the second entity.
Second Entity Profit Share Entitlement	Number	Enter the profit share entitlement percentage for the second entity.
Second Hospital Stay
Second Hospital Name	Text	Enter the name of the hospital for the second hospital stay.
Second Admission Date Day	Text	Enter the day of admission for the second hospital stay. Max length: 2 characters
Second Admission Date Month	Text	Enter the month of admission for the second hospital stay. Max length: 2 characters
Second Admission Date Year	Number	Enter the year of admission for the second hospital stay. Max length: 4 characters
Second Discharge Date Day	Text	Enter the day of discharge for the second hospital stay. Max length: 2 characters
Second Discharge Date Month	Text	Enter the month of discharge for the second hospital stay. Max length: 2 characters
Second Discharge Date Year	Number	Enter the year of discharge for the second hospital stay. Max length: 4 characters
Second Policy Owner Details
Second Policy Owner Full Name	Text	Enter the full name of the second policy owner.
Second Policy Owner Signature Date Day	Date	Enter the day the second policy owner signed.
Second Policy Owner Signature Date Month	Date	Enter the month the second policy owner signed.
Second Policy Owner Full Name
Second Policy Owner Full Name	Text	Please provide the full name of the second policy owner.
Second Policy Owner Signature Date
Second Policy Owner Signature Date Day	Text	Enter the day component of the second policy owner's signature date.
Second Policy Owner Signature Date Month	Text	Enter the month component of the second policy owner's signature date.
Second Policy Owner Signature Date Year	Text	Enter the year component of the second policy owner's signature date. Max length: 4 characters
Self-Employment Type
Sole proprietor	Checkbox	Check this box if your self-employment type is a sole proprietorship.
Contractor	Checkbox	Check this box if your self-employment type is as a contractor.
Shareholder employee	Checkbox	Check this box if your self-employment type is as a shareholder employee.
Companies	Checkbox	Check this box if your self-employment type involves companies.
Partnerships	Checkbox	Check this box if your self-employment type involves partnerships.
Trusts	Checkbox	Check this box if your self-employment type involves trusts.
Other	Checkbox	Check this box if your self-employment type is not listed and then specify the type.
Self-Employment Other Type	Text	Enter the specific type of self-employment if 'Other' is selected.
Specialist Details
Specialist Name	Text	Please enter the full name of the specialist.
Specialist Specialty	Text	Please enter the medical specialty of the specialist.
Specialist Address Street	Text	Please enter the street address of the specialist.
Specialist Address Suburb	Text	Please enter the suburb of the specialist's address.
Specialist Address City	Text	Please enter the city of the specialist's address.
Specialist Address Postcode	Text	Please enter the postcode of the specialist's address.
Specialist Phone	Text	Please enter the contact phone number of the specialist.
Specialist Fax	Text	Please enter the fax number of the specialist.
Specialist Email Address	Text	Please enter the email address of the specialist.
Spouse/Family Member Profit Share Details
Spouse/Family Member Duties	Text	Provide a detailed description of the duties performed by the spouse or family member who is receiving a profit share.
Spouse/Family Member Time on Each Duty	Number	Enter the percentage of time spent by the spouse or family member on each duty.
Symptoms Preventing Work
Symptoms Preventing Work	Text	Please describe the specific symptoms that prevent you from performing your work duties.
Third Compensation Row
Third Compensation: Any sick leave Yes	Checkbox	Check this box if you are claiming or will claim compensation by way of any sick leave.
Third Compensation: Any sick leave No	Checkbox	Check this box if you are not claiming or will not claim compensation by way of any sick leave.
Third Sick Leave Amount	Number	Provide the amount of sick leave compensation received or claimed for this third row.
Third Sick Leave Start Day	Text	Provide the day of the start date for any sick leave compensation for this third row. Max length: 2 characters
Third Sick Leave Start Month	Text	Provide the month of the start date for any sick leave compensation for this third row. Max length: 2 characters
Third Sick Leave Start Year	Number	Provide the year of the start date for any sick leave compensation for this third row. Max length: 4 characters
Third Sick Leave End Day	Text	Provide the day of the end date for any sick leave compensation for this third row. Max length: 2 characters
Third Sick Leave End Month	Text	Provide the month of the end date for any sick leave compensation for this third row. Max length: 2 characters
Third Sick Leave End Year	Number	Provide the year of the end date for any sick leave compensation for this third row. Max length: 4 characters
Third Entity Details
Third Entity Name	Text	Enter the name of the third entity, specifically if it is a partnership.
Third Entity Profit Share Entitlement	Number	Enter the profit share entitlement percentage for the third entity.
Treatment Provided
Treatment Being Provided	Text	Enter the details of the treatment being provided.
Usual Weekly Work Hours
Usual Weekly Work Hours	Number	Enter the number of hours usually worked per week.

Income Protection Claim Form (AIA New Zealand) Instructions