Complete this form if you’re representing ACC, an accredited employer or a third party administrator, and you
need to provide a response to a client’s complaint.
Please email the form to us at [email address]
or post to Office of the Complaints Investigator, PO Box
892, Freepost 264, Hamilton, 3240.
1. Client details
Client name: [Client full name auto]
Claim number: [Claim number auto]
Address: [Client address line 1 auto], [Client address line 2 auto], [Client address line 3 auto], [Client address
Home phone: [Client home phone auto]
Mobile phone: [Client mobile phone auto]
Email address: [Client email auto]
Work phone: [Client work phone auto]
2. Business unit details
ACC business unit/agent/accredited employer name:
Unit manager’s name:
3. Details of complaint
Provide a full and comprehensive timeline of the events relating to the complaint:
If the complaint is about alleged behaviours of individual staff, please provide details:
Please note we may need to speak with the staff member directly, but we’ll speak with the manager(s) first.
List any relevant Eos contacts and attach documents if applicable
Date and time
What steps have been taken by the business unit to work with the client to resolve the issues or find a way
Page 1 of 2
ACC711 Complaint response
What aspects of the complaint do you agree with and why?
What aspects of the complaint do you disagree with and why?
Describe any ACC actions that demonstrate the expected standards of service and fairness to the client:
Please provide the investigator with any other evidence that is not already in Eos:
Any other comments:
4. Staff member details
Form completed by:
Checked by team manager:
When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy
this form to fulfil the requirements of the Accident Compensation Act 2001.
Page 2 of 2