Employer Referral

Check the service that you want to refer to Active+ for:

Return to work service*

Details of these services can be found here.

Client details:

The client I am referring has an ACC injury claim*

The Client is currently receiving weekly compensation from ACC or is likely to be entitled to weekly compensation if vocational assistance is not provided.

ACC Injury Claim Number*

Full Name*

Date of Birth*

Street Address*

Suburb*

City*

Home Phone*

Work Phone

Mobile

Date of Injury (if known)

Do you have a Preferred Provider?*

Diagnosis (if known)

Work Type / Role*

Employer Name, Contact Details and Workplace Address*

I would like you to contact me to let me know more about this service

I have discussed this with my employee and they have consented to you being in touch with them about this service

Employer Referral

Check the service that you want to refer to Active+ for:

Client details:

Upload supporting documents

Links

Phone

Address

Connect

Provida