This information will be used to match you to our employment data.
Claim Reference Number (if known)
First Name*
Surname*
IRD Number*
Date of Birth
Has your name changed since you were a team member of a WISNZ entity?*
Old First Name*
Old Surname*
Preferred Name
Address Line 1*
Address Line 2
City / Town*
Postcode
Country*
Email Address
Preferred Contact Method*
Payment will made into a New Zealand bank account only
Bank Account Number*
Tax Code*
Are you a contributing KiwiSaver member?*
Select your contribution rate
Are you a current member of Wesfarmers AMP fund?
Do you wish to make an after-tax contribution to your AMP fund?
AMP Member Number*
AMP Contribution Percentage*
Please scan or photograph and upload these documents with your claim. Ensure the images are in JPEG, PNG, GIF or PDF format.
Please note: If your identity document has text on both sides (e.g. driver licence), both sides need to be scanned for it to be accepted
You can download the IR330 form here You can download the KS2 form here
IR330*
Identity Verification*
Proof of Name Change*
Privacy Policy: By providing your personal information in this form, you consent to NZ Safety Blackwoods using that information to consider and process your claim. We will not use or disclose personal information collected in this form for any other purpose. If you do not provide the information requested in this form, we may not be able to process your claim. Our Privacy Policy can be found at https://nzsafetyblackwoods.co.nz/en/privacy-policy. You can also email us at privacy@nzsafetyblackwoods.co.nz.