NZ Safety Blackwoods
Safety + Engineering Supplies + Uniform + Packaging
  • Remediation Payment Claim Form

    This information will be used to match you to our employment data.

    • Claim Reference Number (if known)

    • First Name*

    • Surname*

    • IRD Number*

      Please contact the IRD if you are unsure of your number
    • Date of Birth

      By including your date of birth we can process your claim more quickly
    • Name changes

    • Has your name changed since you were a team member of a WISNZ entity?*

    • Old First Name*

      If it has changed since you were a team member of a WISNZ entity
    • Old Surname*

      If it has changed since you were a team member of a WISNZ entity

      You will need to provide documentation showing the name changed from old to new, e.g. a marriage certificate or a statutory declaration
    • Current Contact Details

    • Preferred Name

    • Address Line 1*

    • Address Line 2

    • City / Town*

    • Postcode

    • Country*

    • Email Address

      This may be used for correspondence and/or payment information
    • Preferred Contact Method*

    • Payment Details

      Payment will made into a New Zealand bank account only

    • Bank Account Number*

    • Tax Code*

      See IR330 for list of codes
    • 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*

    • Document Uploads

      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*

      Click Here
      This contains your tax code, IRD number and signature. (A PDF version of this form and further information is available on the IRD website)
    • Identity Verification*

      Click Here
      Any one of birth certificate, passport, certificate of citizenship, Immigration New Zealand visa, driver's licence, firearms licence, or HANZ 18+ card.
    • Proof of Name Change*

      Click Here
      Please attach documentation showing the name change from old to new, e.g a marriage certificate or statutory declaration
    • Declaration

    • 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 You can also email us at