ACC712
Summary of events
This form gives a summary of your complaint and our initial findings.
Please check all the information, including your personal and complaint details, to make sure they’re correct. If
you’d like to change anything please:
complete part 5
return the form to us within 7 days at
[email address] or post to ACC Complaints, PO Box 892,
Freepost 264, Hamilton, 3240.
If you need any help with the form please cal us on 0800 650 222.
1. Client details
Client name: [Client full name auto]
Complaint number: [Complaint number auto]
Address: [Client address line 1 auto], [Client address line 2 auto], [Client address line 3 auto], [Client address
postcode auto]
Home phone: [Client home phone auto]
Mobile phone: [Client mobile phone auto]
Email address: [Client email auto]
Work phone: [Client work phone auto]
2. Client representative or advocate details
Representative’s name:
Phone number:
Email address:
Relationship to the client:
3. Business unit details
ACC business unit/agent/accredited employer name:
Contact name:
Phone number:
Email address:
4. Details of complaint
Date received:
Complaints investigator:
Summary of complaint:
Alleged breach(es) of the Code of ACC Claimants’ Rights:
Summary of information:
Area(s) of disagreement:
ACC712
May 2014
Page 1 of 2
ACC712 Summary of events
Initial findings:
5. Your response to the information on this form
If you’re able to provide more information or if any of the information on this form is incorrect please let us
know below and we may be able to change these initial findings.
You can attach another page if you like.
When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy
Code 1994. For further details see ACC’s privacy policy, available at www.acc.co.nz. We use the information collected on
this form to fulfil the requirements of the Accident Compensation Act 2001.
ACC712
May 2014
Page 2 of 2
